高铁人工排列进路错误的原因分析及预防改进研究

Cause Analysis and Preventive Improvement Research on Manual Route Setting Error of High-Speed Railway

高铁人工排列进路错误虽是小概率事件,但一旦发生将威胁高铁运输安全。采用作业流程分析方法,梳理人工排列进路的各个环节,分析导致人工排列进路错误的主要原因,提出流程优化和再造的预防改进方案;通过调查全路高铁人工排列进路错误的故障数,统计估算在现有作业方式下人工排列进路错误的故障率;运用故障树分析方法,对这些故障率进行定量分析并评估预防改进效果。结果表明:人工排列进路错误主要与人因失误和流程控制缺陷有关,通过优化调度集中控制设备的“操作需确认”设置,能够一定程度地降低人工排列进路故障率;对“窗口确认”和“窗口确定”进行流程改造,分别改进为图形显示的“预览确认”和“预览确定”,能够将人工排列进路故障率降低约2个数量级。

Although the manual route setting errors of high-speed railway is a low probability event,it will seriously threaten the safety of HSR transportation once it happens.By using the method of work flow analysis,individual links in the process of the manual route setting have been put in order and the main reasons for the errors have been analyzed.Then,the preventive improvement scheme for procedure optimization and reengineering is put forward.By investigating the fault number of manual route setting errors across the National Railway,the fault rate of manual route setting errors in existing operation modes is estimated.The Fault Tree Analysis method is used to quantitatively analyze those fault rates and evaluate the effects of the preventive improvement schemes.The results show that the errors of manual route setting are mainly related to human errors and process control defects.The fault rate of manual route setting can be reduced to a certain extent by optimizing the setting of“operation needs to be confirmed”in the Centralized Traffic Control device.Through process reengineering of“window identification”and“window confirmation”,which are improved into“preview identification”and“preview confirmation”in the graphic display,the fault rate of manual route setting can be reduced by approximately two orders of magnitude.