为了系统研究班组决策失误规律,识别核电厂班组决策失误的关键路径,从组织视角出发,结合核电厂所处环境与班组决策失误特征对人因分析与分类系统(Human Factor Analysis and Classification System,HFACS)模型进行改进,建立了核电厂班组决策失误致因模型.利用改进后的模型对137份核电厂事件报告进行统计分析,并运用卡方检验与让步比分析班组决策失误的原因及各层次之间的内在关系.结果表明,组织文化缺失、规程不明晰、知识与能力不足、制定备选方案失误是导致班组决策失误的重要因素.改进HFACS模型中上下层级的因素之间存在显著的因果关系,且容易引发班组决策失误的路径有32条,其中发生概率最大的路径为组织设计不当→ 任务不明晰→压力过大→确定目标失误.由此可见,核电事故的发生是各致因因素相互作用的结果,降低班组决策失误概率需要阻断关键致因路径,加强对关键因素的管控.
Analysis of the causes of team decision-making errors in nuclear power plants from the perspective of the organization
To systematically study the rule of team decision-making error in nuclear power plants,and identify and explore the important factors and critical paths of team decision-making error in nuclear power plants,the Human Factor Analysis and Classification System(HFACS)model was modified from the perspective of organization and combined with the characteristics of the main control room of nuclear power plant,and a team decision-making error cause model was established.The improved model includes four levels:organizational influence,situational influence,unsafe behavior preconditions,and unsafe behavior.The improved model was used to make a statistical analysis of 137 human factor incident reports collected from nuclear power plants,and the frequency statistics of each level of influencing factors were drawn.According to the statistical results,the lack of organizational culture occurs most frequently at the organizational level.The frequency of procedure problems was the highest in the context level.The lack of knowledge and ability occurred most frequently in the level of unsafe behavior prerequisite.In the level of unsafe behavior,the proportion of making alternative plan mistakes is the highest,indicating that the above four factors are the high-frequency factors leading to team decision-making errors.Then,by using the Chi-square test and Odds Ratio(OR)analysis,the causality of team decision-making error in nuclear power plants and the causality between different levels are explored,and the causality model of team decision-making error is obtained.The results show that there is a significant causal relationship between the factors of the upper and lower levels in the model.32 paths are easy to cause team decision-making errors,among which the path with the greatest probability is improper organization design → unclear task →excessive pressure → wrong determination of goals.This is because improper organizational design may lead to team members'insufficient understanding of the task content,leading to greater psychological pressure and resulting in decision-making errors.It can be seen that nuclear power accidents are the result of the interaction of various factors.For nuclear power plants,to reduce and prevent the occurrence of team decision-making errors,they must attach importance to emergency management,start from the source,block the key cause path,and strengthen the control of key factors.Specifically,the management can be optimized from the aspects of improving the relevant organizational management mechanism,paying attention to the construction of a safety culture,providing a suitable operating environment for employees,and strengthening the attention to the physical and mental health of team members.At the same time,team members should also strengthen their knowledge reserve and risk awareness from their point of view,calm and standardized operations when dealing with emergencies.
safety social engineeringteam decision-making errorHuman Factor Analysis and Classification System(HFACS)Chi-square testOdds Ratio(OR)
NETL
NSTL
万方数据
