人的认知可靠性模型在高剂量率后装机卡源应急响应中的应用研究

Study on application of human cognition reliability model in human error in emergency response against the source blockage of high dose rate afterloading unit

目的研究高剂量率（HDR）后装治疗机卡源事件的应急响应操作中的人因可靠性，提出合理可行的安全对策措施，从而提高HDR后装治机的应用安全。方法采用人的认知可靠性（humancognitionreliability，HCR）模型，对HDR后装机卡源应急响应中的10个操作失误类型进行分析，寻找失误原因及其危害，明确允许响应操作的时间窗。通过人员模拟、观摩和记录获取响应操作的执行时间，估算应急响应操作的人因失误概率。结果获得了HDR后装机卡源响应中，操作人员执行的操作动作、相应的允许时间窗和执行时间以及各个动作的人因失误概率，失误概率为0．04—0．27。结论基于HCR模型的HDR后装机卡源应急相应中操作人员的人因失误模型是可行的，从而为降低潜在照射事故的发生或减轻事故后果提供重要参考依据。

Objective To put forward reasonable and feasible recommendations aiming at enhancing the application safety of afterloading unit, through studying the human reliability in the emergency response against the source blockage of afterloadlng unit. Methods Based on the human cognition reliability model, ten operation errors during the emergency response against the source blockage of afterloading unit were analyzed and permissible time widow of emergency response operation were determined. The human error probability was calculated with the execution time of emergency response operation obtained through simulation, observation and recording. Results The operation action, relevant permissible time window and execution time were obtained with the corresponding human error probabilities in the range 0. 04 - 0. 27. Conclusions The human error model in emergency response against the source blockage of afterloading unit based on HCRmodel is feasible, and provides important reference basis to reduce the occurrence of potential exposure and mitigate the consequence of potential exposure.