Research on Data-driven Human Error Causal Mechanism in Nuclear Power Plants
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摘要: 为了辨识人因失误机理，采用组织定向的人因失误分析（OTHEA）技术对2010—2017年国内核电厂发生的137件人因事件报告进行分析，采用相关性和因子分析方法，辨识人因失误影响因素之间的相关关系，识别出触发人因失误的场景，在此基础上，建立人因失误因果机理模型，揭示人因失误机理。结果表明，影响人因失误主要的结合模式为：知识经验水平、信息显示质量、压力水平、注意力与警觉性、安全态度。知识经验水平主要受培训水平和交流水平的影响；信息显示质量主要受技术系统、人-机界面、规程、组织设计的影响；压力水平主要受任务、规程、人-机界面、技术系统、组织设计以及知识经验水平和信息显示质量的影响；注意力与警觉性主要受工作环境、工作组织管理以及信息显示质量的影响；安全态度主要受组织安全文化、工作组织管理以及操纵员的素质与能力的影响。上述研究可为核电厂人因失误的精准防控提供理论依据，提升核电厂的安全水平。Abstract: In order to identify human error mechanism, the Organization-oriented human error analysis (OTHEA) technique is used to analyze the 137 domestic human factor event reports that occurred in nuclear power plants (NPPs) from 2010 to 2017. By using the methods of correlation and factor analysis, the correlation between the influencing factors of human error is identified, and the scene that triggers human error is identified. On this basis, the causal mechanism model of human error is established to reveal the mechanism of human error. The results show that the main combination modes affecting human error are knowledge and experience level, information display quality, pressure level, attention and vigilance, and safety attitude. The knowledge and experience level is mainly affected by the level of training and communication; The information display quality is mainly affected by the technical system, human-machine interface, procedures and organizational design; The pressure level is mainly affected by tasks, procedures, man-machine interface, technical system, organizational design, knowledge and experience level and information display quality; Attention and vigilance is mainly affected by the work environment, work organization and management, and the information display quality; The safety attitude is mainly affected by the organizational safety culture, work organization and management and the quality and ability of operators. The above research can provide a theoretical basis for the precise prevention and control of human error in nuclear power plants, and improve the safety level of nuclear power plants.
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Key words:
- Human error /
- Influencing factors /
- Error mechanism /
- Nuclear power plants
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图 1 组织定向的人因失误因果概念模型
Figure 1. Organization-oriented Conceptual Model of Human Error Causality
表 1 总方差解释表
Table 1. Total Variance Interpretation Table
成分 初始特征值 公共因子 旋转载荷平方和 总计 方差百分比
/ %累积
/ %总计 方差百分比
/ %累积
/ %培训 3.619 25.852 25.852 1 3.313 23.662 23.662 组织设计 2.779 19.849 45.701 2 2.500 17.860 41.522 组织管理 1.844 13.170 58.871 3 2.247 16.051 57.573 组织文化 1.004 7.173 66.045 4 1.186 8.472 66.045 技术系统 0.857 6.124 72.168 人-机界面 0.665 4.752 76.920 规程 0.644 4.598 81.518 任务 0.582 4.159 85.676 交流 0.517 3.695 89.371 工作环境 0.389 2.780 92.151 压力 0.374 2.673 94.824 态度 0.285 2.034 96.857 注意力 0.268 1.915 98.773 素质和能力 0.172 1.227 100.000 表中空白表示无相关数据 
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表 2 旋转后的因子载荷矩阵
Table 2. Factor Load Matrix after Rotation
成分 公共因子 1 2 3 4 培训 −0.096 0.822 −0.093 0.105 组织设计 0.735 −0.157 0.104 −0.057 组织管理 −0.053 0-.086 0.835 0.068 组织文化 −0.131 0.520 0.598 0.021 技术系统 0.708 −0.126 −0.119 0.156 人-机界面 0.721 −0.019 0.125 0.017 规程 0.581 −0.184 −0.081 −0.313 任务 0.765 −0.013 −0.079 0.020 交流 −0.046 0.714 0.164 0.087 工作环境 0.038 −0.012 0.122 0.918 压力 0.872 0.085 0.007 0.094 态度 −0.001 0.404 0.696 −0.155 注意力 0.174 −0.069 0.775 0.400 素质和能力 −0.078 0.887 0.058 0.017
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[1] 张力,王以群,黄曙东. 人因事故纵深防御系统模型[J]. 中国安全科学学报,2002, 12(1): 34-37. doi: 10.3969/j.issn.1003-3033.2002.01.009 [2] 李鹏程. 核电厂数字化控制系统中人因失误与可靠性研究[D]. 广州: 华南理工大学, 2011. [3] REASON J T. Human error[M]. Cambridge: Cambridge University Press, 1990. [4] CHANG Y H J, MOSLEH A. Cognitive modeling and dynamic probabilistic simulation of operating crew response to complex system accidents: part 1: overview of the IDAC model[J]. Reliability Engineering & System Safety, 2007, 92(8): 997-1013. [5] RASMUSSEN J. Risk management in a dynamic society: a modelling problem[J]. Safety Science, 1997, 27(2-3): 183-213. doi: 10.1016/S0925-7535(97)00052-0 [6] LEVESON N. A new accident model for engineering safer systems[J]. Safety Science, 2004, 42(4): 237-270. doi: 10.1016/S0925-7535(03)00047-X [7] LI P C, ZHANG L, DAI L C, et al. A new organization-oriented technique of human error analysis in digital NPPs: model and classification framework[J]. Annals of Nuclear Energy, 2018, 120: 48-61. doi: 10.1016/j.anucene.2018.05.021 [8] 李鹏程,张力,戴立操,等. 数据驱动的操纵员情景意识因果模型研究[J]. 原子能科学技术,2015, 49(11): 2062-2068. doi: 10.7538/yzk.2015.49.11.2062 [9] 李晓芳. 数字化核电厂班组情景意识失误研究[D]. 衡阳: 南华大学, 2019. [10] 李鹏程,张力,戴立操,等. 核电厂操纵员的情景意识失误与预防控制研究[J]. 原子能科学技术,2016, 50(2): 323-331. doi: 10.7538/yzk.2016.50.02.0323 [11] FALKLAND E C, WIGGINS M W. Cross-task cue utilisation and situational awareness in simulated air traffic control[J]. Applied Ergonomics, 2019, 74: 24-30. doi: 10.1016/j.apergo.2018.07.015 [12] FISCHER U, ORASANU J, MONTALVO M. Efficient decision strategies on the flight deck[C]//Proceedings of the 7th International Symposium on Aviation Psychology. Columbus: Ohio State University, 1993: 238-243. -
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