人因失误的后果-前因追溯表

Consequent-antecedent retrospective table for human errors

认知可靠性和失误分析方法(CREAM)属于第二代人因可靠性分析方法。该文研究CREAM中的追溯分析方法在人因失误事件根原因分析中的应用,对人因失误基本原因的分类和后果前因关系进行归纳、整理和补充,给出了简洁的后果前因追溯表和具体的追溯分析步骤和框架,便于实际应用。应用于ThreeMileIsland事故中的一个重要人因失误事件的追溯分析,得出了设计、规程和认知等方面的根原因。结果表明,追溯分析方法在工业系统人因事故的根原因分析中是实用而有效的方法。

The cognitive reliability and error analysis method (CREAM) is a second-generation Human Reliability Analysis method. This paper analysis the root causes of human error using the retrospective analysis method in CREAM. Human error causes are classified. The consequent and the antecedent are related for generalized conditions. A simple consequent-antecedent retrospective table and the process and frame of the retrospective analysis method are given for practical applications. The method was used in a retrospective analysis of the important human error events in the Three Mile Island accident to identify the root causes in the designs, procedures and cognition. The result shows that the retrospective analysis method is very useful for root cause analysis in industrial systems.