人为失误与预防(上海)课件.ppt

1、 Accidents will be often happened in the air,on the highways and railways,but it will be happened at sea as well.事故经常在空中、公路与铁路事故经常在空中、公路与铁路上发生，但也经常在大海上发生。上发生，但也经常在大海上发生。Collision(碰撞碰撞)Grounding(搁浅搁浅)Flooding(进水进水)On Fire(火灾火灾)Pollution(污染污染)Even if we have had good skill or made proper procedure即使我们

2、具有良好的技能或制定了正规的程序，即使我们具有良好的技能或制定了正规的程序，缺少正确的态度，还是会导致事故的发生。缺少正确的态度，还是会导致事故的发生。C=A C=A（K+S K+S）C Capacity C Capacity 能力能力 A Attitude A Attitude 态度态度 K Knowledge K Knowledge 知识知识 S Skill S Skill 技能技能 主要是为了：理念的改变；主要是为了：理念的改变；态度的改变；态度的改变；行为的改变。行为的改变。发现不足，确保成功。发现不足，确保成功。人为失误与预防人为失误与预防HUMAN ERROR&ACCIDENTS人

3、为失误与事故Marine Accidents（海上（海上事故）事故）Maritime accidents or disasters are very seldom the result of a single event.海上事故或灾难很海上事故或灾难很管理管理少是由一个事件造少是由一个事件造成的成的They are almost always the result of series of non-serious incident;the culmination of an ERROR CHAIN.它们几乎总是由一系列不严重的事件导它们几乎总是由一系列不严重的事件导致的致的;它们是失误链发展

4、的最终结果它们是失误链发展的最终结果Definition(定义)nError could be neglect and mistakes 失误为过失与错误。失误为过失与错误。nIt means that you should do,but youhave not done;Which you should notdo,but you have done.你应该做的而未做，不该做的已做了。你应该做的而未做，不该做的已做了。n A Series of events or the chain of events,which leads to an accident 导致事故的一系列事件或事件链导致事

5、故的一系列事件或事件链n Error Chain Links 失误链的连接失误链的连接n Occur sequentially 顺序地发生顺序地发生n May or may not be related;may or may not be apparent 可能有或没有联系可能有或没有联系;可能明显或不明显可能明显或不明显海因里希事故因果链 Heinrichs cause and effect chain of accidentsIdentification(识别)Being aware of the situation around yourself(I.e.Situational Awar

6、eness)helps you recognize the formation of an error chain.Based on this awareness,take the appropriate action to BREAK the chain of events.了解你自己周围局面的情况（即情景意识）帮助了解你自己周围局面的情况（即情景意识）帮助你认识一个失误链的形成，在此认识基础上，采你认识一个失误链的形成，在此认识基础上，采取相应的措施来终止事件链。取相应的措施来终止事件链。Signs (迹象)The signs indicating the formation of an

7、error chain are the same as the signs indicating the loss of situation awareness.表明失误链形成的迹象与丧失情景意识的迹象是表明失误链形成的迹象与丧失情景意识的迹象是一样的。一样的。Thus with the loss of Situational Awareness comes the formation of an Error Chain.因此，丧失情景意识致使失误链得以形成。因此，丧失情景意识致使失误链得以形成。Signs for Indicating the Formation of an Error Ch

8、ain(表明失误链形成的迹象)nA.Ambiguity 不确定性不确定性nB.Distraction 注意力分散注意力分散nC.Feeling of inadequacy or confusion 感知不全面或感知不全面或混乱混乱nD.Communication breaking down通信中断通信中断nE.Improper CONN or lookout 指挥或监测不当指挥或监测不当nF.Departure from condition plan 偏离设定工况偏离设定工况nG.Violation of established rules or procedures 违反已建立的规则或程序违

9、反已建立的规则或程序nH.Complacency自满自满 A.Ambiguity 不确定性nWhen 2 or more independent sources of information appears to disagree 当当二种或二种以上单独的信息源产生矛盾时二种或二种以上单独的信息源产生矛盾时:nPeople 人员人员nEquipment 设备设备nRules,regulations,procedures,systems 法规法规、规则、程序与系统规则、程序与系统nOr any combination of these 或其他合或其他合成的来源成的来源 Ambiguity its

10、elf may not be dangerous,but it means that there is a difference and the cause of this difference needs to be verified.Ambiguity may be a result of inexperience or lack of training.不确定性本身也许不危险，但它意味着有差异，不确定性本身也许不危险，但它意味着有差异，但差异原因需要证实。不确定性也可能是经验不但差异原因需要证实。不确定性也可能是经验不足或缺乏训练的结果足或缺乏训练的结果B.Distraction 注意力

11、分散 Distraction can be caused by:注意力分散可由下列因素造成：注意力分散可由下列因素造成：nBreakdown in Leadership and Management skills 领导与管理的失误；领导与管理的失误；n excessive workload/stress/fatigue 超负荷工作超负荷工作/压力压力/疲劳；疲劳；nemergency situations 紧急情况；紧急情况；n inattention 注意力不集中；注意力不集中；n inexperience 经验不足。经验不足。Focus of attention on one input

12、or component of situational awareness to the exclusion of others，such as a tell call,which can occupy the full attention of a person to the exclusion of other more urgent needs.It is another form of the distraction.注意力集中在一个问题或情景意识的某一方面，例如电注意力集中在一个问题或情景意识的某一方面，例如电话呼叫，它可吸引一个人的全部注意力，从而忽视了处理话呼叫，它可吸引一个人的

13、全部注意力，从而忽视了处理其它更紧迫的事件从而忽视了其它情况。这是注意力分散其它更紧迫的事件从而忽视了其它情况。这是注意力分散的另一种形式。的另一种形式。C.Feeling of Inadequacy or Confusion 感知不全面或混乱 A felling of loss of control of the situation such that the person concerned does not know what is expected to happen next.Frequently the result of lack of experience.对失去局面控制感的人

14、员是不知道随后将会发生什么的。这对失去局面控制感的人员是不知道随后将会发生什么的。这往往是由于经验缺乏造成的。往往是由于经验缺乏造成的。A sense of uncertainty or confusion about a situation caused by lack of professional intuition and cognitive dissonance 对局面难以确定和发生感觉对局面难以确定和发生感觉混乱通常是缺乏职业的直觉和认知不清而发生的。混乱通常是缺乏职业的直觉和认知不清而发生的。D.Communication Breaking Down 通信中断 Internal

15、communications may be confused by physical causes such as noise,etc.or be caused by lack of a common language or differing procedural methods.External communications breakdown may also be caused by a non-common language or plain misunderstanding.船内通信可能被物理因素所干扰，例如噪声等。也可能因船内通信可能被物理因素所干扰，例如噪声等。也可能因缺乏共同

16、语言或不同的处理方法而中断。外部通信的中断可能缺乏共同语言或不同的处理方法而中断。外部通信的中断可能是没有共同语言或误解造成的。是没有共同语言或误解造成的。Improper or poor communications which result in：不正确或不良的通信将导致不正确或不良的通信将导致:Directions not being executed properly 指令不能被正确执行；指令不能被正确执行；The need for repetition of directions.要求重复指示；要求重复指示；Missed Messages 丢失信息；丢失信息；Incomplete a

17、cceptance or understanding of the plan 不能完整的接受和理解计划。不能完整的接受和理解计划。E.Improper CONN or lookout 指挥或监测不当Improper conning and poor lookout may be a result of lack of situational awareness as well as an indication of its breakdown.指挥或监测不当可能是由情景意识不够，指挥或监测不当可能是由情景意识不够，也意味着错误的表现也意味着错误的表现。For examples 例如例如:Not

18、 exercising appropriate control and direction.未能加以适当的控制与指未能加以适当的控制与指挥挥 Excessive speed 超速；超速；Improper operation of the engine 机器不正确的运行机器不正确的运行.Not stationing appropriate lookouts 未能安排好监测人员未能安排好监测人员 Insufficient qualified personnel for the task at hand 身边能胜任工作的人员身边能胜任工作的人员不足。不足。F.Departure from Condi

19、tion Plan 偏离设定工况 Departure from the Planed condition may be a result improper conning or improper monitoring of the operation of the engine.偏离设定工况可能是由于在机器运行中的指挥偏离设定工况可能是由于在机器运行中的指挥或监控不当而造成的或监控不当而造成的。Not building and disseminating the condition of the engine 未制定或落实好未制定或落实好设定工况；设定工况；Unplanned/undresse

20、d departures from a condition of the engine 未能计划未能计划和造成对设定工况的背离；和造成对设定工况的背离；Failure to meet the goals and targets of an established plan without follow-up 未能采取进一步的措施达到已制定计划未能采取进一步的措施达到已制定计划的目的与要求。的目的与要求。G.Violation of Established Rules or Procedures 违反已建立的规则或程序 Departure from clearly defined rules a

21、nd standard operating procedures without justification，such as:Rules of the port auti-pollution,Engine Procedures,Engineering operation and company policy 没有正当理由而背离明确规定的规则和标准操作没有正当理由而背离明确规定的规则和标准操作程序。例如：港口防污程序。例如：港口防污规则规则、机炉舱规则、轮机操机炉舱规则、轮机操作程序和公司政策等。作程序和公司政策等。H.Complacency自满Overconfidence过于自信过于自信；Ov

22、er-familiarity with the route or the task at hand 对手中工作与任务过于熟悉；对手中工作与任务过于熟悉；Ignoring or belittling potential problems 不不考虑和轻视潜在问题；考虑和轻视潜在问题；Being lulled into a false sense of security 自我认为很安全。自我认为很安全。What can cause errors?哪些因素会产生过失?There are many combinations and ways in which errors can occur,both

23、technical errors of ship and human error.过失的产生因素有多种，包括船舶的过失的产生因素有多种，包括船舶的技术性故障和人为失误技术性故障和人为失误。Technical Errors of engine（机器的技术性故障）涉及到机器运行的主要技术参数超限报警，涉及到机器运行的主要技术参数超限报警，如未被发觉，将导致机器处于失控的状态，从而如未被发觉，将导致机器处于失控的状态，从而进一步引起更大的故障。进一步引起更大的故障。Referred to the machine limit exceeding alarm of main technical para

24、meters in running,if not noted,it will lead to wild condition and cause severer troubles.Errors from Equipment and Information因设备与资料产生的失误 nTotal or intermittent failure 完全故障或间歇性故完全故障或间歇性故障障nMalfunction of safety systems and alarms 安全安全系统和报警故障系统和报警故障nMisleading information from uncalibrated instrumen

25、ts 从未标准化的设备获得的错误信息从未标准化的设备获得的错误信息nImproper of system due to an unturned equipment由于某些设备未开启动而造成系统不正由于某些设备未开启动而造成系统不正常常nOut of date information on papers and instraction 图纸和说明书上的错误信息图纸和说明书上的错误信息Human Beings（人）nHuman beings are not machines 人非机器人非机器nHumans are good at assessing the situation applying k

26、nowledge and solving problems.Humans are bad at sustaining long repetitive tasks,concentrating hard for long periods without a break,are subject to tiredness and fatigue and the dulling effects of boredom.人擅长于应用知识来分析局面，解决问题。人不擅长于长人擅长于应用知识来分析局面，解决问题。人不擅长于长时间进行重复工作和长期不间歇地保持精神高度集中，易于时间进行重复工作和长期不间歇地保持精神

27、高度集中，易于因厌烦、疲劳和枯燥而产生迟钝。因厌烦、疲劳和枯燥而产生迟钝。nFor the human errors,it is possible that an operator may make a mistake.对于人为过失而对于人为过失而言，它可能是指操作者也许会犯错误。言，它可能是指操作者也许会犯错误。nThis might be the MM who operates the wrong course,or the OEW who makes an error,or Chief engineer decide wrongly.它可能是机工操作失误、值班轮机员管理不它可能是机工操作

28、失误、值班轮机员管理不当或轮机长决策错误。当或轮机长决策错误。Kinds of Human Error人为过失的种类Unintentional ActionIntentional ActionUnsafe Act&DecisionSlipsLapseMistakesViolationSkill-BasedAttentionalFailure&MemoryFailureRule-Based&Knowledge-basedMistakeKnowledge-basedRoutise&ExceptionalAdapationsBasic ErrorTypesKinds of Human Error人为

29、过失的种类Kinds of Human Error人为过失的种类 A.Slips and lapses 疏忽和差错疏忽和差错 B.Rule-based mistakes 基于法规的错误基于法规的错误C.Knowledge-based mistakes 基于知识的错误基于知识的错误 D.Cultural Conditioning 文化制约文化制约 E.Violation of safe practices 违反安全惯例违反安全惯例Slips&Lapses 疏忽和失误 Distraction and preoccupation 注意力分散和偏见注意力分散和偏见Changes to normal e

30、xpected circumstances 正常可预见环境的变化正常可预见环境的变化Stress and fatigue 压力和疲劳压力和疲劳Kinds of Human Error人类错误的性质 A.Knowledge-Based Mistakes 基于知识的基于知识的错误错误;B.Rule-based Mistakes 基于法规的错误；基于法规的错误；C.Skill-Based Mistakes 基于技能的错误；基于技能的错误；D.Cultural Conditioning 文化的制约；文化的制约；E.Violation of Safe Practice 违反安全惯例。违反安全惯例。A.K

31、nowledge-Based Mistakes 基于知识的错误n Real weakness due to ignorance 由于无知而犯错由于无知而犯错nOver confidence due to ignorance 由于无知而自负由于无知而自负nA mistaken understanding of the principles involved 有关原则的理解错误有关原则的理解错误B.Rule-based Mistakes 基于法规的错误nMaking a quick decision without consideration of the rules；没有考虑法规而草率决定；没有

32、考虑法规而草率决定；nNot noticing when a rule does not work；没有注意到法规不适用；没有注意到法规不适用；nMisapplying to shortcut rules；错误应用错误应用“简化的简化的”法规；法规；Making errors from ambiguous information；由于信息不明确而犯错。由于信息不明确而犯错。C.Skill-Based Mistakes 基于技能的错误nLack of the training 缺乏训练缺乏训练nNot exchange of the experience 不交流经验不交流经验nLess Prac

33、tical Operation 实际操作过少实际操作过少 D.Cultural Conditioning 文化制约 Cultural conditioning can cause embarrassment in the command structure found on board ships.文化制约在文化制约在船上的指挥结构中会造成问题。船上的指挥结构中会造成问题。Some cultures reinforce an acceptance of authority so that it is very difficult to question senior officers with

34、out feeling uncomfortable.有些文化可加强对权威的认可，以致质询高有些文化可加强对权威的认可，以致质询高级船员时因感到不自在而变得十分困难级船员时因感到不自在而变得十分困难Other cultural influences include possible misunderstandings of intentions and a willingness to comply without question.其他文化影响包括可能对意图的误解和其他文化影响包括可能对意图的误解和毫无疑问地服从毫无疑问地服从。E.Violation of Safe Practice违反安全惯

35、例-Complacency 自满自满-Apathy leading to laziness rather than compliance 冷漠导致懒惰而不是遵守；冷漠导致懒惰而不是遵守；-Experimentation 凭经验凭经验；-A desire to push limits rather than comply 被迫执行而不是出自意愿的遵守；被迫执行而不是出自意愿的遵守；-Motivational and behavioral problems individually and in the team 个体或团队的动机与行为问题个体或团队的动机与行为问题 -Sometimes comp

36、lacency means over confidence 有时自满意味着过于自信有时自满意味着过于自信 -It includes the neglect advice from others 它包括忽视别人的建议，它包括忽视别人的建议，-Neglect to consult to books or publications 忽视查阅书或出版物忽视查阅书或出版物-Neglect to consult to Rules and Regulations 忽视查阅法规忽视查阅法规-Departure from condition plan 偏离设定工况偏离设定工况Breaking the Error

37、 Chains破断失误链(1)-Recognizing the possibility of the error chain and relevant linkages 认识失误链与相关的环节存在的可能认识失误链与相关的环节存在的可能性性-Identifying of existing error chain and relevant linkages 辨清现有失误链及其相关的环节辨清现有失误链及其相关的环节-Taking action to break the error chain and making proper measure to prevent the occurrence of

38、 error chain again.采取行动破断失误链并制定防止失误链的采取行动破断失误链并制定防止失误链的再次产生再次产生。-It is difficult to avoid the occurrence of the error chain,but it must to using the Abort Point to break the error chain.虽然难以避免失误链的产生，但必须采虽然难以避免失误链的产生，但必须采用中断点来破断失误链。用中断点来破断失误链。Breaking the Error Chains破断失误链(2)Examination of whether an

39、 error chain in action all the time 始终注意事故链的是否存在始终注意事故链的是否存在Taking action to resolve the event/link prior to an accident 在事故发生前采取措施解决问题在事故发生前采取措施解决问题Breaking an error chain will cause an accident not to happen 破断失误链可避免事故的发生破断失误链可避免事故的发生 How to Avoid Error 如何预防过失的产生 nPlan ahead and know what to expec

40、t and to do 提提前做好计划，知道将要发生什么和怎么做前做好计划，知道将要发生什么和怎么做nDevelop safe routines and habits to ensure most safe practices are covered under normal operations,whilst leaving time and energy to solve difficult problemsApply self checking habits to all activities 培养安培养安全的做法与习惯，保证在正常操作中能使用安全的惯例，以留全的做法与习惯，保证在正常操

41、作中能使用安全的惯例，以留出时间和精力来解决难题。出时间和精力来解决难题。nCheck and monitor others and expect others to check and monitor you 检查和监督其他人，同时也乐于检查和监督其他人，同时也乐于接受他人的检查和监督。接受他人的检查和监督。国际海事组织（国际海事组织（IMOIMO）关于上世纪八、九十）关于上世纪八、九十年代船舶事故高发阶段的统计表，世界四大柴油年代船舶事故高发阶段的统计表，世界四大柴油机制造商上世纪末的统计资料都说明了事故的原机制造商上世纪末的统计资料都说明了事故的原因因8080以上在于人为因素。以上在于人

42、为因素。The statistics of IMO in high The statistics of IMO in high incidence stage of marine accidents in incidence stage of marine accidents in 1980-2000,and the statistic data from 4 1980-2000,and the statistic data from 4 main diesel engine manufactures in the end main diesel engine manufactures in

43、the end of last century all show that the human of last century all show that the human being factor is above 80%in accidents.being factor is above 80%in accidents.表表1 19871991 年世界全损船舶按船型统计年世界全损船舶按船型统计Table 1 The total loss ships statistic by ship form in 1987-1991198719881989Ship formShip formships

44、Gross tonnageships总吨shipsGross tonnageOil shipOil ship91316361113144371191331346429Bulk and Bulk and combination combination carriercarrier24639834548133654171630633728otherother106407503351264978316412745827643Sum totalSum total13911789731001477758561001561078077100表1 19871991 年世界全损船舶按船型统计Table 1 T

45、he total loss ships statistic by ship form in 1987-199119901991Ship formShip formshipsshipsGross tonnageGross tonnageshipsshipsGross tonnageGross tonnageOil shipOil ship1414224884224884181820205016635016632929Bulk and Bulk and combination combination carriercarrier19197046157046155858272772007772007

46、74242otherother10610629162629162624241351354867244867242929Sum totalSum total1391391221125122112510010018218217084641708464100100船舶机械故障分析The analysis of machine failure on boardIn various troublesIn various troubles，the main engine failure is the main engine failure is mostmost，accounting for about3

47、8%accounting for about38%。表2 各种机械发生故障的比例Table2 The failure rate of various machineriesMachine varietyMEDEGERADMVALEElectromotorothermarkhumanhours（)36.619.317.912.35.12.56.3 The sum failure times 7521Failure times（)3815.710.913.78.13.99.7船舶机械故障分析The analysis of machine failure on boardIn main engine

48、 failuresIn main engine failures，the rates of material the rates of material and defiling problem are big and defiling problem are big，respectively is respectively is 24.3%and 24.7%24.3%and 24.7%。表3 按主机故障原因分类的发生故障的比例（%）The failure rate by different causes of main engine(%)DesignmaterialinstallationoperationSpontaneous abrasioncauterydefilevibrationmanagement1.924.37.49.510.510.424.710.01.3