製造環境中人為失誤損失推估模式之研究

Models of Human Error Prediction and Cost Estimation in Manufacturing Environment

劉鴻世(Hunszu Liu)

指導教授 ： 黃雪玲 ； 劉祖華

國立清華大學/工學院/工業工程與工程管理學系/博士(2008年)

摘要

災害事故發生的最主要原因為人為失誤所造成，而其所佔的比重有逐漸上升的趨勢。人為失誤愈來愈嚴重的問題，主要原因乃在於人員在製造系統中所扮演角色的轉變以及管理階層因為不了解人為失誤所造成的損失嚴重性而造成投入改善資源的不足。為了達到有效控制人為失誤所造成的損失，必須針對人為失誤的原因進行資料分析，探討人為失誤的來源，同時發展一套人為失誤損失推估模式。使企業能夠在了解其作業環境中，存在哪些潛在的人為失誤因子，並了解其對公司經營的影響程度，以作出適當的決策，防止意外發生。
傳統人為可靠度評估技術及會計系統無法直接提供評估人為失誤影響所需的損失資訊。此種阻礙，驅使工業界的管理者必須依靠經驗衡量意外事故及傷害預防措施的效益。導致系統安全防護的效率及有效性被質疑，製造活動的穩定性無法被確保。本研究發展一套人為失誤預測及成本估計模式，協助工業界的現場管理者建構潛伏性的人為失誤成本數據收集及估計工具。 本研究主要分為兩部份。第一部份的工作在於發展人為失誤鑑認系統。 藉由系統化的人為失誤鑑認工具（Human Error Identification System Tool, HEIST)分析標準作業程序，找出潛在人為失誤並據以發展人為失誤觀察表，觀察線上操作員實際操作狀況，紀錄發生潛伏性人為失誤的事件。第二部份為損失成本估計模式的發展。藉由文獻回顧及專家界定的方式，確認損失成本項目的定義，然後由生產線經理及組長，利用層級分析法(Analytic Hierarchy Process, AHP)分析成本損失項目, 界定關鍵性損失成本項目及損失金額, 作為發展人為失誤損失成本資料庫的基礎，並且發展出相關的成本計算機制。
本研究發展一套適合製造環境中管理者所使用的人為失誤損失推估模式的決策輔助系統，作為評估潛伏性人為失誤所造成的損失的工具，使決策者能確實掌握現有機器設備的潛伏性人為失誤可能發生狀況及影響，以決定改善的對策及優先次序，預防事件之發生。此外若在事件發生後，也能迅速的利用此系統，計算出公司的損失。

關鍵字

人為失誤 ； 層級分析法 ； 系統化的人為失誤鑑認工具 ； 損失推估

並列摘要

Researches have shown that the human errors have been generally recognized as the major cause of industrial accidents. This problem is worsening by the increasing mental workload of human in modern manufacturing environment and the insufficient company resources spending due to the lack of understanding the loss of human errors. To prevent the accidents from happening, it is necessary for company to access the potential human errors and implement the appropriate control measurements.
Traditional human reliability assessment techniques and accounting system cannot directly provide loss information for assessing the impacts of human errors. This obstacles force industrial managers to justify the proper accident and injury prevention process through their experiences. The efficiency and effectiveness of the system safety barriers are in doubt and the smooth operation of manufacturing activities are insecure.
In this study, a human error prediction and cost estimation model is introduced to facilitate line managers with a proper tool to collect and calculate the total losses of its impact. The analyzer takes the operation procedure as input data and derives the latent human errors tables through the application of Human Error Identification System Tools (HEIST). The error mode tables are used to develop the human error diagnosis checklists. The checklists are used by the managers to observe workers’ daily operations. The critical costs of latent human errors are derived from the results of literature review with the help of line managers and supervisors through the Analytic Hierarchy Process (AHP). Experts’ judgments and pair wise comparison technique are incorporated to interrogate managers’ knowledge of latent human errors and correspondent costs. This approach can overcome the problem of insufficient cost information caused by current accounting system and compensate the influence of safety and health department due to the low organizational status in quo. The loss estimation model not only provides quantitative data, which can be integrated with the current hazard analysis and risk assessment process, but also identified the root causes of losses and respective correction measurements.

並列關鍵字

Human errors ； AHP ； HEIST ； Loss estimation

參考文獻

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