人因事件深层次管理原因的“FOCUS”分析法

The "FOCUS" Analysis Method for the Deep Management Reasons of Human Error Events

针对当前人因事件根本原因分析中存在的问题,在国际先进的根本原因分析理论基础上,提出了有效识别人因事件背后深层次管理原因的"FOCUS"分析法。上述方法对提高根本原因分析质量、避免类似人因事件重复发生具有积极的意义。

In view of the problems existing in the analysis of the root causes of human error events at present,based on the international advanced theory of root cause analysis,the paper puts forward the"FOCUS"analysismethod that can effectively analyze the deepmanagement reasons behind the human error events.Themethod is of positive significance for improving the quality of root cause analysis and avoiding the recurrenceof similarhuman error events.