人为失误与预防(上海).ppt

Accidents will be often happened in the air, on the highways and railways, but it will be happened at sea as well. 事故经常在空中、公路与铁路上发生，但也经常在大海上发生。 Collision (碰撞) Grounding (搁浅) Flooding (进水) On Fire (火灾) Pollution (污染) Even if we have had good skill or made proper procedure 即使我们具有良好的技能或制定了正规的程序， 缺少正确的态度，还是会导致事故的发生。 C = A ×（ K + S ） C – Capacity 能力 A – Attitude 态度 K – Knowledge 知识 S – Skill 技能 主要是为了：理念的改变； 态度的改变； 行为的改变。 发现不足，确保成功。 Human Error Accidents  人为失误与预防 HUMAN ERROR ACCIDENTS人为失误与事故Marine Accidents（海上事故） Maritime accidents or disasters are very seldom the result of a single event. 海上事故或灾难很管理少是由一个事件造成的They are almost always the result of series of non-serious incident; the culmination of an ERROR CHAIN.它们几乎总是由一系列不严重的事件导致的;它们是失误链发展的最终结果 Definition (定义) Error could be neglect and mistakes 失误为过失与错误。 It means that you should do, but you have not done; Which you should not do, but you have done. 你应该做的而未做，不该做的已做了。 Identification (识别)  Being aware of the situation around yourself (I.e. Situational Awareness) helps you recognize the formation of an error chain. Based on this awareness, take the appropriate action to BREAK the chain of events. 了解你自己周围局面的情况（即情景意识）帮助你认识一个失误链的形成，在此认识基础上，采取相应的措施来终止事件链。　 Signs (迹象) The signs indicating the formation of an error chain are the same as the signs indicating the loss of situation awareness. 表明失误链形成的迹象与丧失情景意识的迹象是一样的。 Thus with the loss of Situational Awareness comes the formation of an Error Chain. 因此，丧失情景意识致使失误链得以形成。 Signs for Indicating the Formation of an Error Chain (表明失误链形成的迹象) A. Ambiguity 不确定性 B. Distraction 注意力分散 C. Feeling of inadequacy or confusion 感知不全面或混乱 D. Communication breaking down通信中断 E. Improper CONN or lookout 指挥或监测不当 F. Departure from condition plan 偏离设定工况 G. Violation of established rules or procedures 违反已建立的规则或程序 H. Comp