故障分析和风险评估中的错误类型分类

A. Sutcliffe, G. Rugg
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引用次数: 53

摘要

我们在Reason(1990)和Hollnagel(1993)的工作基础上描述了错误类型的分类。分类法使用细分为层的分面模式。每一层针对一个特定的分析任务,并提出一种方法来引导评估者通过不同层次(例如认知、社会、组织)的错误类型集。这允许将失败的原因归因于一种或多种错误类型。通过两个不同故障的案例分析说明了该方法。讨论了分类分析在了解故障原因和风险评估中的应用。
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A Taxonomy of Error Types for Failure Analysis and Risk Assessment
We describe a taxonomy of error types that builds on work by Reason (1990) and Hollnagel (1993). The taxonomy uses a faceted schema subdivided into layers. Each layer targets a particular analysis task, and a method is proposed leading the assessor through sets of error types at different levels (e.g. cognitive, social, organizational). This allows the causes of failure to be attributed to one or more error types. The method is illustrated with two case studies of diverse failures. The utility of taxonomy analysis in understanding the reasons for failure and risk assessment is discussed.
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