人為失誤辨識技術整合與應用－以化學品鋼瓶更換作業為例

Integration and Application of Human Error Identification Techniques on Chemical Cylinder Change Task

鄭慶民(Ching-Min Cheng)

指導教授 ： 黃雪玲

國立清華大學/工學院/工業工程與工程管理學系/碩士(2013年)

摘要

本研究統整了數種現行用以評估與分析潛在人為操作失誤的人為失誤辨識技術，雖然這些技術為數眾多且發展已有數十年，但其發展的過程往往配合各產業的特色而無法跨領域通用，且各方法的分析重點及目標亦不盡相同，無法徹底了解人員操作時的外在行為反應以及相對應的心理反應機制。因此，本研究將以整合現有各界常用的人為失誤辨識技術為目標，探討各技術方法的分析邏輯與優缺點，透過各分析方法的互補與結合，包括同時考慮外在失誤模式、內在失誤模式、心理錯誤機制與績效塑成因子四種失誤模式與影響因素，以規劃能夠更完整預測潛在人為失誤的過程。本研究以某個案廠的化學品液體鋼瓶更換流程為主要對象，透過整合後的人為失誤辨識技術評估其操作流程，並得到各種可能發生的操作失誤以及避免失誤發生的改善方法。透過本研究方法的應用並配合研究對象的分析結果可得知：相較於其他人為失誤辨識技術，本研究所提出的整合方法能夠運用在所有的領域，且評估結果更能夠提供更多有效的資訊以及改善方案。

關鍵字

人為失誤 ； 人為失誤 ； 人為可靠度分析 ； 失誤偵測 ； 安全管理

並列摘要

This paper outlines the human error identification (HEI) techniques currently existent to assess and analyze latent human errors. Even if many formal error identification techniques have existed for years, few have been validated to cover latent human errors analysis in different domains. This study considers lots of possible error modes and influential factors that include external error modes, internal error modes, psychological error mechanisms and performance shaping factors, and integrates a number of execution procedures and frameworks of human error identification techniques, including hierarchical task analysis, task classification, error analysis, consequence analysis, reliability analysis and remedy analysis, to identify the latent human errors and to evaluate the human reliability in a case plant. The case study in this research is the operational process of changing chemical cylinder in the manufactory. In addition, the integrated HEI method is used to assess the operational processes and system reliability. It is concluded that the integrated method and analysis procedure is a valuable aid to develop much safer operational processes and can be used to predict human error rates of critical tasks in the plant.

並列關鍵字

human errors ； error modes ； human reliability analysis ； error detection ； safety management

參考文獻

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