本研究之目的在找出化工廠人員可靠度和不安全行為的構成及因素。研究方式主要分成三個大項,第一部份為問卷分析,目的在了解人員對失誤的主關概念,第二為失誤分析,目的在將失誤進行定性及定量,第三為作業現場實地看察,目的在評估化工工作失誤模式。 在失誤分析中,丙烯醇槽車灌充和醋酸乙烯人員灌充作業中發現了74個可能的潛在人為失誤,其中行動失誤佔了最大的一個部份(59/74),再以Ramussen法分類動作層級,在丙烯醇槽車灌充和醋酸乙烯人員灌充作業的主要失誤類型為技巧層面(34/74)與規則層面(33/74)。失誤率預測方面,槽車灌充作業中失誤率最高之動作為防護具繫緊腰部和安全鎖勾上欄杆(0.0015);人員灌充作業中失誤率最高之動作為移出灌裝臂(0.04)。這個結果有助於未來化工作業的失誤模式建立以改善其制度或作業流程,避免失誤發生。 關鍵詞:人為可靠度、不安全行為、人為失誤、化工廠事故
The goal of this study is to discover the construction and factors of human reliability and un-safety behaviors in a chemical factory, the operation of tanker with allyl alcohol and the operation of filling vinyl acetate were investigated. The methods of this study contain three parts. Part one is using questionnaire to survey the error self-knowledge, Part two is using error analysis to define errors in the quantity and quality. Part three is investigating the work activity to evaluate the error mode. For the operation of tanker with Allyl Alcohol and the operation of filling Vinyl Acetate, action errors has occupied a major part (59/74), Then based on the Ramussen principle of motion levels of prescription, for the operation of tanker with Allyl Alcohol and the operation of pouring Vinyl Acetate, The major part are skill-based (34/74) and the ruled-based (33/74). About the operation of tanker, the highest error rate was 0.0015 and the actions are wearing protective equipment and puting the safe lock to hook in the railing. About the operation of filling, the highest error rate was 0.04 and the action is removing the filling arm to another tank. This result help to establish the error model to improve the operation procedure or the system and to prevent these errors from happening again in chemical factories. Keyword: human reliability, un-safety behaviors, human error, chemical industrial accidents