基于CREAM的城市轨道交通事故行车调度员人因失误前因追溯分析

Retrospective Analysis of Human Cause Errors of Urban Rail Transit Accidents Based on CREAM

在CREAM前因追溯表的基础上结合城市轨道交通的具体作业确定城市轨道交通的后果-前因追溯表,以地铁追尾事故为实例追溯其根原因,分别是错过观察或辨识、精神状态差、决策失误、违规违章、计划目标错误、不完善的规程、生理状态差、培训不充分,对根原因进行模糊层次分析,得到其权重因子。根据结果发现行车调度员所处情景环境的薄弱环节,在调度员、调度技术、调度组织有关的方面进行改进,从而提高城市轨道交通行车调度员的人因可靠性。

Based on the CREAM antecedent retrospective table,combined with the specific operation of urban rail transit to determine the consequences of urban rail transit-antecedent retrospective table,taking the subway rear-end accident as an example to trace its root cause,which are missed observation or identification,poor mental state,Mistakes in decision-making,violation of rules and regulations,wrong planning goals,imperfect procedures,poor physiological status,insufficient training,and fuzzy-level analysis of root causes to obtain their weighting factors.According to the results,it is found that the weak link in the scene environment of the dispatcher is improved in terms of dispatcher,dispatch technology and dispatch organization,so as to improve the human factor reliability of the urban rail transit traffic dispatcher.