Murphy D M, Paté-Cornell M E
Brattle Group, Cambridge, Massachusetts 02138, USA.
Risk Anal. 1996 Aug;16(4):501-15. doi: 10.1111/j.1539-6924.1996.tb01096.x.
Complex engineered systems, such as nuclear reactors and chemical plants, have the potential for catastrophic failure with disastrous consequences. In recent years, human and management factors have been recognized as frequent root causes of major failures in such systems. However, classical probabilistic risk analysis (PRA) techniques do not account for the underlying causes of these errors because they focus on the physical system and do not explicitly address the link between components' performance and organizational factors. This paper describes a general approach for addressing the human and management causes of system failure, called the SAM (System-Action-Management) framework. Beginning with a quantitative risk model of the physical system, SAM expands the scope of analysis to incorporate first the decisions and actions of individuals that affect the physical system. SAM then links management factors (incentives, training, policies and procedures, selection criteria, etc.) to those decisions and actions. The focus of this paper is on four quantitative models of action that describe this last relationship. These models address the formation of intentions for action and their execution as a function of the organizational environment. Intention formation is described by three alternative models: a rational model, a bounded rationality model, and a rule-based model. The execution of intentions is then modeled separately. These four models are designed to assess the probabilities of individual actions from the perspective of management, thus reflecting the uncertainties inherent to human behavior. The SAM framework is illustrated for a hypothetical case of hazardous materials transportation. This framework can be used as a tool to increase the safety and reliability of complex technical systems by modifying the organization, rather than, or in addition to, re-designing the physical system.
复杂的工程系统，如核反应堆和化工厂，有可能发生灾难性故障并带来灾难性后果。近年来，人为因素和管理因素已被公认为此类系统重大故障的常见根本原因。然而，经典的概率风险分析（PRA）技术并未考虑这些错误的潜在原因，因为它们侧重于物理系统，并未明确解决组件性能与组织因素之间的联系。本文描述了一种解决系统故障的人为和管理原因的通用方法，称为SAM（系统-行动-管理）框架。从物理系统的定量风险模型开始，SAM扩展了分析范围，首先纳入影响物理系统的个人决策和行动。然后，SAM将管理因素（激励措施、培训、政策和程序、选拔标准等）与这些决策和行动联系起来。本文的重点是描述最后这种关系的四个行动定量模型。这些模型探讨了行动意图的形成及其作为组织环境函数的执行情况。意图形成由三种替代模型描述：理性模型、有限理性模型和基于规则的模型。然后分别对意图的执行进行建模。这四个模型旨在从管理角度评估个体行动的概率，从而反映人类行为固有的不确定性。针对危险材料运输的假设案例对SAM框架进行了说明。该框架可作为一种工具，通过改变组织来提高复杂技术系统的安全性和可靠性，而不是重新设计物理系统，或者除重新设计物理系统之外还改变组织。
