人误原因因素灰色关联分析

Grey Relativity Analysis of Human Error Causal Factors

主要探讨人误原因因素对人误的影响主、次问题.根据建立的人误原因因素层次架构,运用灰色系统理论中的关联分析方法,结合某组织近几年发生的人因事件及根原因分析方法,定量分析计算得到:影响人误的主因素次序为组织、个人、技术和环境因素;影响人误的主要子因素为管理控制因素,其次为素质因素等.同时,分析了同一主因素下的子因素对其主因素的关联情况以及同一层次因素之间的关联情况.

The paper mainly discusses the sequence of casual factors which impacts upon human errors. According to hierarchical framework of human error causal factors, relativity analysis method in grey systems theory, human factor events in certain organization and Root Cause Analysis, the results by quantitative calculation are obtained as following： the order of main factors causing human error is organizational factor, personal factor, technical factor and environmental factor. The most important one among various sub-factors contributing to human errors is managerial control factor, and the second one is the quality factor and so on. The various relativity among sub-factors under the same main factors and the relativity among factors in the same layer are analyzed simultaneously.