Premature Stopping Points for Determining the Root Cause of Human Error in Process Incident Investigations

机译：用于确定过程事件调查中人为错误的根本原因的过早停止点

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This paper focuses on the "failure to follow procedure" cause of process incidents and examines potential underlying reasons that result in employees failing to follow established written procedures. Real-life common incident scenarios are used to demonstrate opportunities to improve incident investigation effectiveness. Concepts of human reliability and human factors are explored as they relate to incident investigation activities. The focus of this paper is on those human factors and human error issues that can be influenced by the findings of the incident investigation.

机译：本文侧重于“未能遵循程序”过程事件的原因，并审查导致员工未能遵循既定书面程序的潜在基本原因。现实生活常见事件方案用于展示提高事故调查效率的机会。探讨了人类可靠性和人为因素的概念，因为它们与事件调查活动有关。本文的重点是那些可能受到事故调查结果影响的人为因素和人为错误问题。

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《Centre for Chemical Process Safety International Conference and Workshop》|2000年||共20页
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Jack Philley;
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中图分类生产安全技术;
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Premature Stopping Points for Determining the Root Cause of Human Error in Process Incident Investigations

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