核电站运行事件人误因素交互作用分析

Interactive Analysis of Human Error Factors in NPP Operation Events

简要介绍了核电站运行事件中人误因素之间的交互作用。从世界核电厂营运者联合会(WANO)1999～2008年的645份运行事件分析报告中筛选出人因事件432件,对事件的根原因和原因因子进行分类统计,并运用统计分析软件SPSS进行相关性分析。结果表明:①工作人员的实际操作受到多因素制约,形成良好的操作习惯是一个系统性的工作,需要多方面的支持;②口头交流、实际操作、人-机接口、程序文件这4个因素非常重要,并且经常捆绑性地同时出现,因此,如果对其中某一方面进行改进,则需考虑对其他几方面同步进行相应改进才可能有效;③管理方针和决策过程这2个与管理相关的因子同人员相关因子之间的交互作用较为显著。

Interactive of human error factors in NPP operation events were introduced,and 645 WANO operation event reports from 1999 to 2008 were analyzed,among which 432 were found relative to human errors.After classifying these errors with the Root Causes or Causal Factors,and then applying SPSS for correlation analysis,we concluded：（1） Personnel work practices are restricted by many factors.Forming a good personnel work practices is a systematic work which need supports in many aspects.（2）Verbal communications,personnel work practices,man-machine interface and written procedures and documents play great roles.They are four interactional factors which often come in bundle.If some improvements need to be made on one of them,synchronous measures are also necessary for the others.（3） Management direction and decision process,which are related to management,have a significant interaction with personnel factors.