基于CREAM追溯分析法的地铁司机人因失误研究

Research on Human Error of Subway Drivers Based on CREAM Retrospective Analysis Method

深入探讨地铁司机人因失误事故发生的根原因,对提高地铁司机人因可靠性以及地铁运行安全有着重要意义。首先依据人的行为与意向的关系,将人因失误模式划分为疏忽、遗忘、错误、违规;结合历史地铁人因事故统计、原因分析及专家意见,构建了涵盖与人有关的、与技术有关的、与组织有关的和与环境有关的4个维度的地铁人因失误事故前因分类表;并应用后果—前因之间的归因追溯关系,确定了失误模式—前因表和后果—前因追溯表,提出了一种基于CREAM追溯分析法的地铁司机人因失误分析法。最后进行了实证分析,分析结果与事故调查报告一致。

It is of great significance to improve the human reliability of subway drivers and the safety of subway operation through deeply exploring the root cause of human error accidents of subway drivers.Firstly,according to the relationship between human behavior and intention,the human error mode is divided into oversight,omission,mistake and violation.Combined with the statistics,cause analysis and expert opinions of historical subway human error accidents,the antecedent classification table of subway human error accidents covering four dimensions of human,technology,organization and environment is constructed.By applying the attribution relationship of consequence-antecedent,the table of error mode-antecedent and the retrospective table of consequence-antecedent are determined,and a subway drivers'human error analysis method based on CREAM retrospective analysis method is proposed.Finally,an empirical analysis is carried out,and the analysis results are consistent with the accident investigation report.