ヒューマンエラーとリスクアセスメント：森山 哲 氏 （PDF
Contents
1.2.
3. 1999 2008 07 26 17 2008 07 26 18 SRK Rasmussen 1976 1 5 Omission error Commission error 9 2
4. 2008 07 26 12 8 1 13 2 60 70 ME 2 51 1 6 3 19 75 4 2 4 75 5 1 3 8 6 3 7 N O 0 80 7 31 20 8 07 46 9
5. 1 0 0 1 0 01 0 00001 A 0 00001 0 1 1984
6. ISO12100 1 1 ISO14121 1 ISO14121 1 ISO14121 1 ISO14121 1 2008 07 26 ISO14121 1 44 IMedHHerfs A high high high high high high high nediuny 2 medium fnediuryfnediun medium 3 Significant Human Error fnedium ow low A neglgible 8 A G W A A I high high lon high 4 WI 1
7. 3 2008 07 26 55 2008 07 26 56 fF 8 2
8. 3 9 2 6 FE 3 0 Rasmussen SRK Reason Violation 2008 07 26 19 2008 07 26 20 Rasmussen SRK Behavor Conscious Knowledge based Problem solver Cons cious efforts Rule based Select procedure Skill based 2 Automatic Automatic routine work Input Output Rule Based 2008 07 26 21
9. ET gt eki as jic EU 1989 06 12 2000 2008 07 26 31 2008 07 26 32 1 NRE es 1 CT EET1
10. 20 Mu kc 3 4 10 20 0 5 3 6 2008 07 26 53 2008 07 26 54 1 I 2
11. 2008 07 26 2008 07 26 6 Any member of a set of human actions that exceeds RN some limit of acceptability Rigby 1970 a An out of tolerance actions which the limits of tolerable performance are defined by the system Swain 1983 lt Ge Sn a NN 1 1 1991 2008 07 26 8 2008 07 26 70 0 0 http Www
12. 2008 07 26 Toerris human 2008 07 26 2008 07 26 1 2 3 2008 07 26 miss mistake 2008 07 26
13. 2 Ny i 4 U 3 1 2 ANSI B11 TR3 MIL STD 882D 2 3 4 DIN V19250 1994 ISO13849 1 3 2008 07 26 35 2008 07 26 36 C
14. MOV 10 E 1 MOV 10 10 2 1 0 11 10 E 1 WASH 1400 Table Il 6 2008 07 26 25 2008 07 26 26 No HEP 1 4 10 E 3 2 3x10 E 3 3 1 10 E 3 4 10 E 2 5 10 E 1 6 1 2 10 E 1 7 10 E 4 8 10 E 3 9 10 E 1 10 10 E 3 11 10 E 2 NUREG CR 1278
15. Swain 1983 2008 07 26 41 2008 07 26 42 zz 70 0 23 46 1 4 Vigilance effectiveness 30 2 3 1 5 max p 120 1979 2008 07 26 43 ISO14121 1 ISO14121 1 SOP ISO14121 1 SOP
16. 3 EL 2008 07 26 57 RN 2008 07 26 58 1 2 3 4 Probabilistic risk assessment of engineering systems Mark G Stewart Robert E Melchers 5 Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications NUREG CR 1278 Swain A D Guttman H E 6 WASH 1400 Reactor Safety Study An Assessment of Accident Risks in U S Commercial Nuclear Power Plants Rasmussen 1975 7 19 8 18 9 ISO14121 1 2007 Safety of machinery Risk assessment Part 1 2008 07 2
17. 2008 07 26 23 10Pbits 1 1 gt ls 1 1093bits sec 102bits sec 107bits sec RC 2008 07 26 24 No 10 E 4 10 E 3 3x10 E 3 10 E 3 3x10 E 3 3x10 E 2 1 X 1 2 3 4 5 6 7 8 9
18. 5 3 Stewart 1997 Probablistic Risk Assessment of Engineering Systems 2008 07 26 13 2008 07 26 14 4 1986 4 26 2 A 31 1960 Rasmussen WASH 1400 i A TMI F TR RN 1930 1980 1995 2008 R n 1993 08 07 26 15 2008 07 26 56 16
19. 2008 07 26 49 2008 07 26 50 2 3 es Skill base Slip 2008 07 26 51 2008 07 26 52 Mu 1 18 3 28 2 0 A 2
20. Reason 1990 Siip Lapse Unsafe act Mistake Violation 2008 07 26 22 3x106 bisec 3x104 biVsec EN i
21. 1 9 7 31 5 8 2 1 2 2 3 4 5 mai 2008 07 26 33 2008 07 26 34 gt 8 G 1 5 gt ee
22. ISO14121 1 2007 R e C P RR s 1 R Risk C P C The severity of harm Consequence of the hazardous event P The probability of occurrence of that harm P P f E O A 2 E The exposure of person s to the hazaro O The occurrence of a hazardous event A The technical and human possibilities of avoiding or limiting the harm 1 2 R R F C P f C E O A 3 2008 07 26 37 C 1 7 500 2 3 4 7 500 6 4 14 x300 365 2008 07 26 38 P The
23. 6 1 2 1 high a 5 j a 4 3 medium mediu low low 2 Exist Human Error 5 i lt S2 A I I low low low A negligible 1 Pt 4 4 J I ve likel 7 83 W Probability 4 high high Nor high 3 1 likely high high medium low unlikely 1 fedium fneduy ow 6 1 Insignificant Human Error 84 remote low low Anegligible A negligible Ss 83 EE E 8 E Adopted from ANSI B11 TR3 2000 Severity 2008 07 26 45 2008 07 26 S P P H 3 2 1 3 145 720 70 144 69 25 24 1 23 14 13 10 R S P F H 1 R x P x F x H
24. 2008 07 26 27 2008 07 26 28 7 bh What Why A 92 0 Gr H 2008 07 26 29 2008 07 26 30 2 4 EU Fra 5 EE eH
25. 2008 07 26 47 2008 07 26 1 i Skill base Violation Et i 1500
26. 6 59
27. mhlw go jp houdou 2008 05 dlh0522 1a_0001 pdf 007 12 2549 2550 4gg 2 1 357 694 1 032 30313233343536373839404142434445464748495051525354555657585960616263 2 3 4 5 6 7 8 9 1011 jp 17 18 19 2 1 620 2004 4 132 248 8 2004 2008 07 26 10 4 80 52 2004 5 2008 07 26 11 1
28. probability P E O A O The occurrence of a hazardous event 2008 07 26 39 PSF ISO14121 1 2007 JIS B9702 ISO 1999 2008 07 26 40 PSF PSF PSF
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