某飛彈發射架拆組裝作業人為可靠度分析

Human Reliability Analysis for Decomposed & Assembling Work Tasks at Missile Launcher

游龍哲(Lung-Che Yu)

指導教授 ： 呂志維

中原大學/電機資訊學院/工業與系統工程研究所/碩士(2013年)

https://doi.org/10.6840/cycu201300662

摘要

本研究係針對國軍某飛彈發射架拆組裝作業進行人為可靠度的評估及改善。研究方向分為三部分：首先依拆組裝的標準作業程序將工作項目以層分方式展開，並訪談作業人員實際作業上產生的各類失誤；其次透過問卷調查蒐集技術人員對於各項失誤發生頻率的主觀意見；最後以人為失誤的評估方法將失誤動作定性及定量，並針對失誤率較高的動作進行改善。
根據問卷分析的結果，影響人員作業失誤最顯著的因素是教育訓練頻率。而失誤分析的部份，發射架拆組裝作業的失誤類別中主要是以動作失誤為主(95/114)，比例高達83.3%。在失誤率預測的部分，評估發射架拆組裝作業中，失誤率最高的動作均為「由具證照人員啟動操作」，失誤率分別為0.19及0.16，顯見此項目確有精進的必要。研究歸納出兩個結論：發射架的拆組裝作業可藉由年資累積來增加工作經驗，進而降低失誤的發生機率; 在累積足夠經驗之前，為了保證作業的品質與安全，亦可透過有計畫的訓練，使人員在作業上有效提升可靠度。而本研究中發現的作業問題，擬以下列建議加以改進: 利用HTA圖強化風險管理、整合資深人員工作經驗、作業組長勤前宣導、管控作業中品質、確保訓用比例、研擬防處措施。
會有失誤產生多屬人為因素，但身為管理者就要盡力確保作業安全，如果每個人都能抱持這種心態，所謂「人為失誤」自然不復存在。

關鍵字

HEART ； SHERPA ； 人為失誤 ； 人為可靠度

並列摘要

In this study, we estimate and improve the human reliability for the army factory technicians disassembling and assembling some missile launcher equipment. The method of study is divided into three parts: 1)follow the standard operating procedure of disassembling and assembling to spread the tasks by tree structure, and interview with people to understand the failure activities of complete operation; 2)use questionnaire to collect the error self-knowledge data; 3) Finally, apply human error analysis approach to define errors in the quantity and quality, and improve the higher failure rate, and reduce the human error rate, and promote the human reliability.
According to the results of the questionnaire, the most evident factor which influences with failures is training frequency. For the failures analysis, the human error type of disassembling and assembling missile launcher equipment is action error (95/114), it has occupied 83.3% in major part. In the disassembling and assembling task, the highest error action both are operate machine by that has license, error rate are 0.19 and 0.16. It’s clear to see this action is necessary to be promoted and strengthen. We could get two conclusions in this study. First, it could increase experience by accumulating work time in the disassembling and assembling task to reduce the human error rate. Second, to assure the quality and safety of task, we can promote the human reliability by regular training before accumulating enough work experience. We can improve those problems in this study by using following suggestions, risk management, integrates experienced staff work experience, advocacy before working, quality control in work, ensure the training proportion, develop prevention methods.

並列關鍵字

SHERPA ； human reliability ； human error ； HEART

參考文獻

11. 謝東甫, 光電廠化學槽車進卸料作業人為可靠度分析. 中原大學工業與系統工程學系碩士論文, 2011.

12. 鍾明正, 國軍某飛彈系統拆卸及組裝作業人為可靠度分析. 中原大學工業與系統工程學系碩士論文, 2013.

7. 黃如瑋, 輪班生活對健康影響知多少. 勞工安全衛生簡訊, 2001(47): p. 2-3.

8. 張其文, 虛驚事件檢討為基礎之安全管理機制先期研究. 國立高雄第一科技大學環境與安全衛生工程所碩士論文, 2004.

5. 陳正信, 台灣省近十年來重大職業災害統計分析報告, 行政院勞工委員會八十一年度全國勞工安全衛生研討會資料彙編, Editor 1992: 台北. p. 17-54.