Baysari Melissa T, McIntosh Andrew S, Wilson John R
University of New South Wales, NSW 2052, Australia.
Accid Anal Prev. 2008 Sep;40(5):1750-7. doi: 10.1016/j.aap.2008.06.013. Epub 2008 Jul 9.
Forty rail safety investigation reports were reviewed and a theoretical framework (the Human Factors Analysis and Classification System; HFACS) adopted as a means of identifying errors associated with rail accidents/incidents in Australia. Overall, HFACS proved useful in categorising errors from existing investigation reports and in capturing the full range of relevant rail human factors data. It was revealed that nearly half the incidents resulted from an equipment failure, most of these the product of inadequate maintenance or monitoring programs. In the remaining cases, slips of attention (i.e. skilled-based errors), associated with decreased alertness and physical fatigue, were the most common unsafe acts leading to accidents and incidents. Inadequate equipment design (e.g. driver safety systems) was frequently identified as an organisational influence and possibly contributed to the relatively large number of incidents/accidents resulting from attention failures. Nearly all incidents were associated with at least one organisational influence, suggesting that improvements to resource management, organisational climate and organisational processes are critical for Australian accident and incident reduction. Future work will aim to modify HFACS to generate a rail-specific framework for future error identification, accident analysis and accident investigation.
审查了40份铁路安全调查报告，并采用了一个理论框架（人因分析与分类系统；HFACS），作为识别与澳大利亚铁路事故/事件相关错误的一种手段。总体而言，HFACS在对现有调查报告中的错误进行分类以及获取所有相关铁路人因数据方面被证明是有用的。结果显示，近一半的事件是由设备故障导致的，其中大多数是维护或监测计划不足的产物。在其余案例中，与警觉性降低和身体疲劳相关的注意力失误（即基于技能的错误）是导致事故和事件的最常见不安全行为。设备设计不足（如驾驶员安全系统）经常被认定为一种组织影响因素，并且可能是导致因注意力失误而引发的事故/事件数量相对较多的原因。几乎所有事件都与至少一种组织影响因素相关，这表明改善资源管理、组织氛围和组织流程对于澳大利亚减少事故和事件至关重要。未来的工作将旨在修改HFACS，以生成一个针对铁路的框架，用于未来的错误识别、事故分析和事故调查。
