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Abu, Hawwach Mohammed. "Human errors in industrial operations and maintenance". Thesis, Mälardalens högskola, Innovation och produktrealisering, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:mdh:diva-54794.
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Within maintenance activities and industrial operations, human is subjected to different kind of stresses and situation that could result in mistakes and accidents. The human errors in maintenance and manufacturing are an unexplored latter such that a little focusis invested in this area. The report aims to widen up the understanding of the human error in maintenance and manufacturing area. Aviation and marine operations are the most sectors that are subjected to human errors according tothe literature. There aredifferent types of human error that have effect on quality and overall effectivity. Human reliability models are one method to quantify human errors and usually used for the identification of human errors and HEP calculation. The most common reliability measurement methods are HEART, THERP and SLIM which are used depending on application and industry. As a part of efforts to define differences between those reliability models, literature including different industries is used and itis found that expert judgement influences the success and accuracy of such methods. There are many causes for human errors depending on the application but, communication and procedures followed are the most contributing factors. There is always a probability of existence of human errors as the mistake done by workers are inevitable. Industry 4.0 can help in decreasing human errors through the introduction of operator 4.0 as well as other approaches like training and upgrading organizational standards.
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Balasubramanian, Prashanth. "Root cause analysis-based approach for improving preventive/corrective maintenance of an automated prescription-filling system". Diss., Online access via UMI:, 2009.
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Thesis (M.S.)--State University of New York at Binghamton, Thomas J. Watson School of Engineering and Applied Science, Department of Systems Science and Industrial Engineering, 2009.Includes bibliographical references.
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Bayramyan, Anna. "Making success out of failures : A quantitative research in Failure culture and Quality improvement". Thesis, Mittuniversitetet, Institutionen för kvalitets- och maskinteknik, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-40261.
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Companies can draw valuable lessons from their failures, and use them for their improvementwork. A positive failure culture is however a necessary precondition. High reliabilityorganisations (HRO) are known for their effective way of tackling and using failures aspotential for improvements. The aims of the study were to evaluate failure culture in an ISO9001 certified company, after HRO standards and thereby withdraw improvementpossibilities. The study was conducted through a deductive quantitative method using asurvey for data gathering. With approximately 30 percent response rate, and using statisticaltests, the failure culture of the company was evaluated. The results showed that the companyis not currently reaching a failure culture within HRO standards, but nevertheless has positivetendencies rather than negative. Lastly, improvement possibilities were discussed andsuggestions for further research were given.2020-06-26
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Maier, Carl. "Elektronisk plattform för förebyggande underhåll på utrustning". Thesis, Högskolan i Skövde, Institutionen för informationsteknologi, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:his:diva-18657.
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Preventive maintenance is a process employed to reduce probability of failure or degradation of equipment. When such a process is performed by humans without a computerized solution, human errors are bound to take place. A computerized solution could reduce human errors by automatically performing tasks which are prone to error. A React web and a React Native application are created to evaluate which framework is most suitable for use in a preventive maintenance process based on three criteria. The criteria are round-trip request times, lines of code and delivery time based on build size. Results show that the React web application outperforms the React Native application in all three categories.
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Slack, Sean Edward. "Essays on categorical and universal welfare provision : design, optimal taxation and enforcement issues". Thesis, University of St Andrews, 2016. http://hdl.handle.net/10023/15659.
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Part I comprises three chapters (2-4) that analyse the optimal combination of a universal benefit (B≥0) and categorical benefit (C≥0) for an economy where individuals differ in both their ability to work and, if able to work, their productivity. C is ex-ante conditioned on applicants being unable to work, and ex-post conditioned on recipients not working. In Chapter 2 the benefit budget is fixed but the test awarding C makes Type I and Type II errors. Type I errors guarantee B > 0 at the optimum to ensure all unable individuals have positive consumption. The analysis with Type II errors depends on the enforcement of the ex-post condition. Under No Enforcement C > 0 at the optimum conditional on the awards test having some discriminatory power; whilst maximum welfare falls with both error propensities. Under Full Enforcement C > 0 at the optimum always; and whilst maximum welfare falls with the Type I error propensity it may increase with the Type II error propensity. Chapters 3 and 4 generalise the analysis to a linear-income tax framework. In Chapter 3 categorical status is perfectly observable. Optimal linear and piecewise-linear tax expressions are written more generally to capture cases where it is suboptimal to finance categorical transfers to eliminate inequality in the average social marginal value of income. Chapter 4 then derives the optimal linear income tax for the case with classification errors and Full Enforcement. Both equity and efficiency considerations capture the incentives an increase in the tax rate generates for able individuals to apply for C. Part II (Chapter 5) focuses on the decisions of individuals to work when receiving C, given a risk of being detected and fined proportional to C. Under CARA preferences the risk premium associated with the variance in benefit income is convex-increasing in C, thus giving C a role in enforcement.
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Ishihara, Yasuo. "Prediction of human error in rail car maintenance". Thesis, Massachusetts Institute of Technology, 1996. http://hdl.handle.net/1721.1/10629.
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McCracken, Michael E. "Maintenance Error Information System (MEIMS) upgrade and training evaluation". Thesis, Monterey, Calif. : Springfield, Va. : Naval Postgraduate School ; Available from National Technical Information Service, 2000. http://handle.dtic.mil/100.2/ADA387421.
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Thesis (M.S. in Information Technology Management) Naval Postgraduate School, Dec. 2000.Thesis advisors, Schmidt, John K. ; Brinkley, Douglas. "December 2000." Includes bibliographical references (p. 127-130). Also available in print.
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Fry, Ashley D. "Modeling and analysis of human error in Naval Aviation maintenance mishaps". Thesis, Monterey, Calif. : Springfield, Va. : Naval Postgraduate School ; Available from National Technical Information Service, 2000. http://handle.dtic.mil/100.2/ADA381266.
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Saward, Justin R. E. "Individual Latent Error Detection (I-LED) in UK naval aircraft maintenance". Thesis, University of Southampton, 2017. https://eprints.soton.ac.uk/417856/.
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System-induced human error is the most significant factor in aircraft accidents; for which errors are both inevitable and a frequent occurrence. Human error is a by-product of performance variability caused by system failures, for which undetected error becomes a latent error that can impact system safety and therefore contribute to a future undesired outcome. The phenomenon of Individual Latent Error Detection (I-LED) is proposed. ILED refers to the detection of workplace latent errors at some point post-task completion through the recollection of past activity by the individual who suffered the error. An extensive literature review shows the phenomenon to be a novel concept, indicating a clear gap in knowledge requiring research to explore the nature and extent of I-LED events. A multi-process theory is developed and combined with the systems perspective to provide a theoretical framework upon which to conduct real-world observations of ILED events in cohorts of naval air engineers. Collected data indicate time, location and other system cues trigger I-LED events, for which the deliberate review of past activity within a time window of two hours of the error occurring and whilst remaining in the same sociotechnical environment to that which the error occurred appears most effective. Several practicable interventions are designed and tested, from which the overall benefit of integrating the I-LED phenomenon as an additional safety control within an organisation’s safety system is assessed. This thesis contributes to knowledge on workplace safety by applying systems thinking to understand the nature and extent of I-LED and its benefit to safety resilience in naval aircraft maintenance through enhanced operator competence to detect latent errors. I-LED research arguably offers a step-change in safety thinking by offering a level of resilience within the workplace that has not previously been accounted for in organisational safety strategies.
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Schmorrow, Dylan D. "A human error analysis and model of naval aviation maintenance related mishaps". Thesis, Monterey, California. Naval Postgraduate School, 1998. http://hdl.handle.net/10945/44430.
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Approved for public release; distribution is unlimitedNaval Aviation is in the midst of a major transformation as it attempts to come to terms with the demands of maintaining operational readiness in the face of diminishing budgets and reduced manning. Diminishing operating and procurement budgets mean that Naval Aviation is for the most part "making do" with existing aircraft. Over the past decade, one in four Naval Aviation mishaps were partially attributable to maintenance error. The present operating environment underscores the need to address maintenance error and its causes. The current study accomplishes three things. First, it evaluates 470 Naval Aviation mishaps with distinct maintenance error correlates. Second, it categorizes those errors using a taxonomy based upon current organizational and psychological theories of human error. Third, it mathematically models the consequences of these errors and uses the models to (a) predict the .frequency with which maintenance-based mishaps will occur in the future and (b) approximate the potential cost savings from the reduction of each error type.
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Zarinkhail, Mohammad Shuaib. "Static MySQL Error Checking". University of the Western Cape, 2010. http://hdl.handle.net/11394/8492.
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Masters of ScienceCoders of databases repeatedly face the problem of checking their Structured Query Language (SQL) code. Instructors face the difficulty of checking student projects and lab assignments in database courses. We collect and categorize common MySQL programming errors into three groups: data definition errors, data manipulation errors, and transaction control errors. We build these into a comprehensive list of MySQL errors, which novices are inclined make during database programming. We collected our list of common MySQL errors both from the technical literature and directly by noting errors made in assignments handed in by students. In the results section of this research, we check and summarize occurrences of these errors based on three characteristics as semantics, syntax, and logic. These data form the basis of a future static MySQL checker that will eventually assist database coders to correct their code automatically. These errors also form a useful checklist to guide students away from the mistakes that they are prone to make.
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Baltazar, Ana Rita Duarte Gomes Simões. "Erro humano e erro organizacional nas atividades de manutenção das aeronaves na perspetiva da Grounded Theory : o caso nacional". Doctoral thesis, Instituto Superior de Economia e Gestão, 2020. http://hdl.handle.net/10400.5/20577.
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Doutoramento em GestãoNos últimos anos ocorreram situações que demonstram que os acidentes em organizações de elevada fiabilidade têm consequências catastróficas que precisam de ser contidas ou evitadas. As medidas para a contenção e prevenção do erro estão estabelecidas nesse tipo de organizações, mas focalizam-se em evitar as consequências negativas dos erros, não analisando as consequências positivas dos mesmos (quando existem). A literatura aponta como consequências positivas a aprendizagem, a inovação e a resiliência. O trabalho conclui que de forma conceptual a consequência positiva dos erros é um aumento da Segurança Organizacional através de processos de melhoria associados à Aprendizagem Organizacional. O erro humano não deve ser primariamente entendido como a principal causa dos acidentes, mas antes como uma possível consequência da atividade organizacional. Foi necessário compreender como (How) ocorre e porque (Why) ocorre o erro organizacional; e, ainda, qual a relação entre os diferentes níveis de erro (humano, de equipa e organizacional) e os fatores organizacionais. Esta abordagem transportou o investigador para a necessidade de uma análise aprofundada do conceito de condições/erros latentes. O conhecimento das causas primárias de um incidente/acidente poderá levar a que se criem indicadores que sirvam de alertas em situações futuras e/ou se alterem essas mesmas condições para que se evitem situações idênticas. Verificou-se neste trabalho que cada incidente/acidente, depois de estudado, é uma fonte de informação absolutamente essencial para a melhoria do sistema. No entanto, existem outras fontes que necessitam de ser mais estimuladas, nomeadamente, o reporte de ocorrências e a correspondente análise e partilha de resultados na Organização. A investigação recorre a uma metodologia qualitativa e os resultados aplicam-se apenas à Organização em estudo. O modelo final explica como através do erro de manutenção aeronáutica, na Força Aérea Portuguesa, se aumenta a Segurança Organizacional.
In recent years, situations have occurred which demonstrate that accidents in High Reliability Organizations have catastrophic consequences that need to be restrained or avoided. Measures to contain and prevent errors are established in this type of organizations, but focus on avoiding the negative consequences of errors, thus not analyzing their positive consequences (when they exist). The literature points to positive consequences of learning, innovation and resilience. The study concludes that, in a conceptual way, the positive consequence of the errors is an increase of the Organizational Security through processes of improvement associated with the Organizational Learning. Human error should not be primarily understood as the main cause of accidents, but rather as a possible consequence of organizational activity. It is necessary to understand how and why organizational errors occur; and the relationship between the different levels of error (human, team and organizational) and organizational factors. This approach transported the researcher to the need for an in-depth analysis of the concept of latent conditions / errors. Knowing the root cause of an incident / accident may lead to the creation of indicators that serve as warnings in future situations and / or change the same conditions, so that similar situations are avoided. It was verified in this study that each incident / accident, once studied, is an absolutely essential source of information for the improvement of the system. However, there are other sources that need to be more stimulated, namely the reporting of occurrences and the corresponding analysis and sharing of results in the organization. The research uses a qualitative methodology and the results apply only to the organization being studied. The final model explains how the Organizational Safety is increased, through the aeronautical maintenance error in the Portuguese Air Force.
info:eu-repo/semantics/publishedVersion
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Nelson, Douglas B. "Information management system development for the investigation, reporting, and analysis of human error in Naval Aviation Maintenance". Thesis, Monterey, Calif. : Springfield, Va. : Naval Postgraduate School ; Available from National Technical Information Service, 2001. http://handle.dtic.mil/100.2/ADA397263.
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Thesis (M.S. in Information Technology Management)--Naval Postgraduate School, Sept. 2001.Thesis advisors, Schmidt, John K. ; Figlock, Robert C. ; Zolla, George A. "Septemebr 2001." Includes bibliographical references (p. 71-74). Also available in print.
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Mattmuller, Adam. "Nuclear Power Plant Maintenance Improvement via Implementation of Wearable Technology". The Ohio State University, 2016. http://rave.ohiolink.edu/etdc/view?acc_num=osu1461760209.
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Wood, Brian P. "Information management system development for the characterization and analysis of human error in Naval Aviation maintenance related mishaps". Thesis, Monterey, Calif. : Springfield, Va. : Naval Postgraduate School ; Available from National Technical Information Service, 2000. http://handle.dtic.mil/100.2/ADA384625.
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Thesis (M.S. in Information Technology Management)--Naval Postgraduate School, Sept. 2000.Thesis advisor(s): Sengupta, Kishore ; Schmidt, John K. ; Ciavarelli, Anthony. "September 2000." Includes bibliographical references (p. 89-94). Also available in print.
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Boex, Anthony R. "Web-based information management system for the investigation, reporting, and analysis of human error in Naval Aviation maintenance". Thesis, Monterey, Calif. : Springfield, Va. : Naval Postgraduate School ; Available from National Technical Information Service, 2001. http://handle.dtic.mil/100.2/ADA397001.
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Thesis (M.S. in Information Technology Management) Naval Postgraduate School, Sept. 2001.Thesis advisors: Schmidt, John K., Zolla, George A., Figlock, Robert C. "September 2001." Includes bibliographical references (p. 291-293). Also available online.
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Domrow, Nathan Craig. "Design, maintenance and methodology for analysing longitudinal social surveys, including applications". Thesis, Queensland University of Technology, 2007. https://eprints.qut.edu.au/16518/1/Nathan_Domrow_Thesis.pdf.
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This thesis describes the design, maintenance and statistical analysis involved in undertaking a Longitudinal Survey.
A longitudinal survey (or study) obtains observations or responses from individuals over several times over a defined period. This enables the direct study of changes in an individual's response over time. In particular, it distinguishes an individual's change over time from the baseline differences among individuals within the initial panel (or cohort). This is not possible in a cross-sectional study. As such, longitudinal surveys give correlated responses within individuals. Longitudinal studies therefore require different considerations for sample design and selection and analysis from standard cross-sectional studies.
This thesis looks at the methodology for analysing social surveys. Most social surveys comprise of variables described as categorical variables.
This thesis outlines the process of sample design and selection, interviewing and analysis for a longitudinal study. Emphasis is given to categorical response data typical of a survey.
Included in this thesis are examples relating to the Goodna Longitudinal Survey and the Longitudinal Survey of Immigrants to Australia (LSIA). Analysis in this thesis also utilises data collected from these surveys. The Goodna Longitudinal Survey was conducted by the Queensland Office of Economic and Statistical Research (a portfolio office within Queensland Treasury) and began in 2002. It ran for two years whereby two waves of responses were collected.
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Domrow, Nathan Craig. "Design, maintenance and methodology for analysing longitudinal social surveys, including applications". Queensland University of Technology, 2007. http://eprints.qut.edu.au/16518/.
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This thesis describes the design, maintenance and statistical analysis involved in undertaking a Longitudinal Survey. A longitudinal survey (or study) obtains observations or responses from individuals over several times over a defined period. This enables the direct study of changes in an individual's response over time. In particular, it distinguishes an individual's change over time from the baseline differences among individuals within the initial panel (or cohort). This is not possible in a cross-sectional study. As such, longitudinal surveys give correlated responses within individuals. Longitudinal studies therefore require different considerations for sample design and selection and analysis from standard cross-sectional studies. This thesis looks at the methodology for analysing social surveys. Most social surveys comprise of variables described as categorical variables. This thesis outlines the process of sample design and selection, interviewing and analysis for a longitudinal study. Emphasis is given to categorical response data typical of a survey. Included in this thesis are examples relating to the Goodna Longitudinal Survey and the Longitudinal Survey of Immigrants to Australia (LSIA). Analysis in this thesis also utilises data collected from these surveys. The Goodna Longitudinal Survey was conducted by the Queensland Office of Economic and Statistical Research (a portfolio office within Queensland Treasury) and began in 2002. It ran for two years whereby two waves of responses were collected.
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Harris, Brenden Roy. "Design to maintenance: A new construction design and building life cycle management approach". Thesis, Queensland University of Technology, 2021. https://eprints.qut.edu.au/213059/1/Brenden_Harris_Thesis.pdf.
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The thesis develops a systematic and innovative approach to integrating commercial building design and maintenance so as to advance the body of knowledge of building life cycle management. Different from other studies, this approach extended the beneficial outcomes beyond the traditional capital focused outcome to the whole building life cycle. Participatory action research was employed and a number of mega commercial project case studies have demonstrated the research has improved traditional engineering practices significantly by linking design and error costs to maintenance, which resulted in improving asset life and values.
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Lin, TsungPo. "An adaptive modeling and simulation environment for combined-cycle data reconciliation and degradation estimation". Diss., Atlanta, Ga. : Georgia Institute of Technology, 2008. http://hdl.handle.net/1853/24819.
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Thesis (Ph.D.)--Aerospace Engineering, Georgia Institute of Technology, 2008.Committee Chair: Dimitri Mavris; Committee Member: Erwing Calleros; Committee Member: Hongmei Chen; Committee Member: Mark Waters; Committee Member: Vitali Volovoi.
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Beckman, Erik, i Linus Harenius. "Monitored Neural Networks for Autonomous Articulated Machines". Thesis, Mälardalens högskola, Akademin för innovation, design och teknik, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:mdh:diva-48708.
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Being able to safely control autonomous heavy machinery is of uttermost importance for the conversion of traditional machines to autonomous machines. With the continuous growth of autonomous vehicles around the globe, an increasing effort has been put into certifying autonomous vehicles in terms of reliability and safety. In this thesis, we will investigate the problem with a deviation from the planned path for an autonomous hauler from Volvo Construction Equipment. The autonomous hauler has an error within the kinematic model, the feed-forward curvature-steering controller, due to a slip-effect that comes with the third wheel-axle. The deviation can especially be seen in sharp curves, where the deviation needs to be decreased in order to make the autonomous hauler more dependable and achieve an increased accuracy when following any given path. The aim of the thesis is to develop a fully functional Artificial Neural Network that has a new steering angle as output. The hypothesis for this thesis is to use an ANN to mimic the steering of a human driver, since a real driver compensates for the slipping behavior; both because the operator knows where on the road the machine is and also in the way that a human thinks many steps ahead whilst driving. This proposed ANN will have a monitor function which ensures that the steering angle command operates within its boundaries. Hence this thesis implies that it is indeed possible to ensure that the ANN performs reliably with the help of a monitor function in a simulated environment and can thus be used in dependable systems.
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Lu, Po-Chi, i 盧柏琪. "On The Causes of Aircraft Maintenance Errors and Improvement". Thesis, 2013. http://ndltd.ncl.edu.tw/handle/54296043431119928452.
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碩士銘傳大學
企業管理學系碩士在職專班
101
Past studies on the human factors related to aviation incidences focused mainly on flight crews and air traffic controllers, and few were on the aircraft maintenance issues. With the technological advances in designing and manufacturing aircrafts, reliability and safety of airplanes has been drastically increased, while the importance of aircraft maintenance is not given equal emphasis. In this study, we collected maintenance related cases in the last three years from the focal company and analyzed possible grouping of all identified causes for human errors to see if there were possible correlations. We further interviewed people who were involved in the cases to gather their opinions of possibly ignored caused that were undetected when the cases were originally discussed in the focal company. The results show that some possible causes for human errors were missing from the previous analysis and some managerial recommendations are provided.
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Wang, Wen-Ying, i 王文音. "Optimal Inspection Strategy with Inspection Errors, Rework and Preventive Maintenance". Thesis, 2008. http://ndltd.ncl.edu.tw/handle/23769752469924543079.
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博士國立中央大學
企業管理研究所
96
In spite of the implementation of modern technology and an efficient control procedure to improve equipment, the deterioration of the production process is unavoidable in most manufacturing industries. Inspections and maintenance activities are performed in virtually every production system. In this study, we construct models that allow us to economically determine the optimal inspection/disposition strategy for a batch of items produced by a machine that is subject to random breakdowns. We use the proposed mathematical framework to explore the issues relating to inspection errors, rework, preventive maintenance level, and minimal repair. The operational implications of the optimal strategy are then analyzed with a selected set of numerical results. We formulate dynamic programming of optimal strategy for two types of inspection activities: inspection of products and inspection of production systems. For inspection of products, we develop models of off-line inspection for a deterioration process having general shift distribution with an increasing hazard rate. To have an off-line inspection following an unreliable process is an appropriate quality assurance tactic in certain systems. Previous work has dealt exclusively with finding the point where the process shifts away from its in-control state to an out-of-control state. Our models incorporate the economic aspects of the inspection activity and of the two types of product inspection errors. Ignoring the true economics of quality assurance can result in unnecessary costs and time delays. We determine the first unit inspected and the average number to be inspected in a batch. We also study the effect of allowing rework on the optimal inspection strategy. For inspection of production systems, we generalize the classical economic production quantity model to consider possibilities of preventive maintenance errors and minimal repair. Our model solves simultaneously the optimal number of inspections, the duration of the first inspection interval, the economic production quantity, and the preventive maintenance level. Despite the strong interdependence between production, quality and maintenance, these three main aspects of any manufacturing system are traditionally modeled as separate problems. Few attempts have been made to integrate them in a single model that captures their underlying relationships. Our study essentially explores models for the joint optimization of production quantity, quality assurance inspections, and maintenance level. Our results demonstrate that these different but interrelated aspects of a manufacturing system can be captured rigorously in a united framework. Numerical simulations also illustrate the importance of viewing all theses decisions concerning core manufacturing processes in an integrated manner, rather than as a set of separate decisions.
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Wu, Chia-Hsiang, i 吳佳祥. "A Study on the Relationships among Line Maintenance Staff's Human Errors,Job Satisfaction,and Organizational Commitment in the Airline Industry". Thesis, 2018. http://ndltd.ncl.edu.tw/handle/8a38pj.
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碩士元智大學
管理碩士在職專班
106
Aircraft maintenance is a process of ensuring that all systems on the aircraft continue to perform their intended functions at the level of safety design and reliability. Without the contribution of maintenance personnel, the aviation industry can not operate, however, due to job characteristics, line maintenance tend to have higher error rate than other maintenance departments, which in turn poses a threat to flight safety. Human error is the result of interactions between individuals, workplaces, and organizational factors. It often has a negative impact on the job performance of maintainer, and may even result in flight incidents. Therefore, this study intends to study the relationship between human error and the organizational behaviors from the aspects of job satisfaction and organizational commitment of the line maintenance staff. This study conducted a questionnaire survey to collect data from the line maintenance staff of a major airline in Taiwan. A total of 241 valid questionnaires were collected. The results of statistical analysis revealed that the main error factors influencing the line maintenance staff include “Fatigue”, “Pressure”, “Stress” and “Destructive-Workplace Norms”.Job satisfaction has a negative impact on “Lack of Communication” , ”Leak of Awareness” , “Pressure” , “Fatigue” , and “Destructive-Workplace Norms” among human errors.Organizational commitment have a negative impact on “Lack of Communication” , “Leak of Awareness” , “Fatigue” , “Pressure” among human errors.
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Cajee, Muhammad Yousuf. "Applying Attribution Theory to Perceptions of Maintenance Error". Thesis, 2007. http://hdl.handle.net/10539/2030.
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Student Number : 9802206M -
MA dissertation -
School of Psychology -
Faculty of HumanitiesBefore this study took place, the social psychology perspective of Attribution theory was yet to be fully utilised in South African research within the maintenance error landscape. Attributional approaches see the person on the street operating like a scientist, obtaining information from his or her social surroundings and discerning the causes and consequences of ongoing behavioural and environmental events (Harvey et.al.,1976). It is very possible that due to the unique South African socio-political and economic landscape, strongly influenced by Apartheid, new combinations of known and unknown error attributions are at play, that are unique to this landscape and have not yet been studied or uncovered. Thus, a better understanding of the South African landscape, through a study such as this, could have serious cost benefits to maintenance companies, benefits to staff in terms of reduced risk of injury, as well as form the basis of improved policies, procedures and equipment. Twenty-five team leaders and 125 minor maintenance staff at a South African Aircraft Maintenance Company formed the population group from which the sample for this study was drawn. Within each group, 5 individuals were interviewed on a personal basis. Further, for each group, one focus group was carried out consisting of two and four individuals respectively. The individuals who participated in the focus groups were different to those who participated in the interviews. In total 28 percent of team leaders participated in the study and 7 percent of maintenance staff, which calculates to just over 10 percent of minor maintenance employees at the organisation involved. The Qualitative data acquired through this in-depth interview and focus group discussion process, and subsequent transcription was coded and analysed using Thematic Content Analysis. Content analysis is a research technique for making replicable and valid inferences from data to their context (Krippendorf, 1980). The discussion of primary error attributions comparing maintenance staff and team leaders, focussed on the predominant primary error attribution theme and related attributions under the descriptor Organisational Culture which included both the dimensions of employee motivation and managerial culture. Finally, results of secondary error attributions comparing maintenance staff and team leaders raised the discussion around the theme, Tools and Equipment. This research is an exploratory study that brings together the field of attribution theory and maintenance error. Its main strength is that it provides a theoretical framework, upon which is based a methodology that explores the primary and secondary error attributions made by employees for maintenance errors in their work environment. In other words, it is felt that this methodology can be implemented in a range of maintenance environments to unearth the error attributions of staff in that environment. Information such as this is very beneficial to companies and organisations in their planning, strategising, problem solving and general organisational development.
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Blanks, Mark Thomas. "Feasibility of the Application of the Maintenance Error Decision Aid Process to General Aviation Maintenance". 2007. http://trace.tennessee.edu/utk_gradthes/250.
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The purpose of this study was to determine the feasibility of applying the Maintenance Error Decision Aid (MEDA) that was developed by Boeing to general aviation maintenance shops, either in its current form or with limited modification. The MEDA investigation process has been implemented successfully by several major airlines and it was assumed that general aviation could also benefit from this safety enhancing process. Because of the nature of the MEDA process, this paper only addresses the feasibility of applying the MEDA process to large shops. After consulting aviation professionals and performing extensive research, a questionnaire was created and sent to numerous general aviation (GA) maintenance managers to determine their opinion of the feasibility of the application of MEDA to GA. A total of 6 responses were received and analyzed, from which it was concluded that the MEDA system could enhance safety in general aviation with certain alterations to the system.
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Chiu, Yen-Wen, i 邱彥文. "Applying HFACS-ME for Human Error of Aircraft Maintenance". Thesis, 2012. http://ndltd.ncl.edu.tw/handle/52647956048647869605.
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碩士開南大學
空運管理學系
101
Today the globalization has brought rapid development. It is expected that airline transportation volume in the future will be increased on a large scale. The ‘flight safety” and “economic effects”—the two pressures which the counterpart airline companies undertake will also be increased. How to improve flight safety is the issue which airline enterprises should face and explore. According to the statistics of International Air Transport Association (IATA), 80% of all the accidents related to flight safety are concerned with human error. However, most enterprises have not made a detailed analysis and taken action to deal with them regarding these records and data to find out the main factors of human error. This study uses “Maintenance Extension of the Human Factors Analysis and Classification System (HFACS-ME)” as the framework of theories. It is aimed to study the target airlines whose aircraft line maintenance departments caused abnormal incidents because of human error in the recent three years (2009-2011). The study will make an independent analysis of their maintenance paper reports and explore the sub-items of different levels that affect aircraft maintenance, that is, the human factor related to human error. After the research results of statistics and certification, the study has discovered that the first three sub-items are respectively the first-level “Judgment/Decision-making”, the fourth level “Inadequate processes” as well as the third-level “Inadequate training/Preparation”, which shows that the errors caused by “Judgment/Decision-making” is the foremost key factor of human factors concerned with airplane maintenance. In addition, through the association analysis of different levels, the study will find out the obvious genres and invariables existing between high levels and low levels, use the τ coefficient brought forth by Goodman & Kruskal as the inspection vector with the purpose of finding the path of levels and also use Odds Ratio to display the intensity of association. With the results obtained from the above-mentioned inspection and analysis, we can understand the mutual influences of high levels and low levels. The ordering of human factors and the association of between-levels derived from this study can be provided to airline companies that under the circumstances of limitation of resources, can focus on the risk factors of management and apply it to Safety Management System (SMS) with the hope that the occurrence probability of human error can be reduced to the minimum.
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Guidi, Giulia. "The importance of human factor and maintenance activities in risk assessment for railway applications". Doctoral thesis, 2022. http://hdl.handle.net/2158/1264674.
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This thesis focuses on the importance of human factor and maintenance activities in risk assessment for railway applications.
Risk based maintenance is a key factor of RAMS (Reliability, Availability, Maintainability and Safety) for railway. One of the widest used techniques to evaluate the optimal maintenance policy of complex systems is the RCM (Reliability Centred Maintenance). This procedure starts from a failure analysis before individuating the optimal maintenance operation focusing on a decision diagram which is very vague and subjective. Trying to solve this problem, the first part of this work introduces an innovative approach that proposes a new decision-making diagram. The new diagram is based on a fuzzy-FMECA (Failure Modes, Effects and Criticality Analysis) assessment combined with some Boolean variables in order to provide a unique maintenance task for every identified scenario depending on the O (Occurrence), S (Severity) and D (Detection) assessment. The proposed procedure provides a diagnostic-oriented decision diagram able to solve the problems of the standardized RCM procedure and, at the same time, to optimize the Operation&Maintenance cost and the system availability favoring CBM (Condition-Based Maintenance) tasks such as Condition Monitoring and Failure Finding procedures.
The proposed enhanced RCM is based on a FMECA, which is a central technique used to perform risk assessment in every industrial and technological field. Despite this, several papers in literature agree that classical FMECA suffer many drawbacks. The developed fuzzy FMECA technique aims to solve all these problems with a simple and effective tool that could be applied in railway applications. Moreover, an innovative risk threshold estimation method has been developed to divide critical and negligible modes after the FMECA assessment in order to prioritize countermeasures.
The second topic covered by this research is the analysis of human reliability in railway engineering. Human factors remarkably contribute to railway accidents and, as a matter of fact, it is one of the main causes of accident on the last years. This is the reason why it is mandatory to study and evaluate human reliability in maintenance operation of railway systems. Literature is plenty of techniques developed to study the human reliability, however the only validated method for railway field is RARA (Railway Action Reliability Assessment). RARA has been developed in 2012 and is characterized by a highly subjective and complex assessment. Trying to solve these needs, this work proposes an improvement of RARA method able to solve its main shortcomings thanks to fuzzy logic. Using the proposed fuzzy-RARA the analyst is facilitated in the assessment of the numerical parameters and the subjectivity is remarkably mitigated.
Finally, the last part of the work presents an innovative technique specifically developed for railway. This method integrates the Weibull distribution and aims to provide a time-dependent model for the Human Error Probability. Furthermore, the proposed method gave the possibility to select one or more variable breaks within the work shift, which is an aspect generally neglected by the state-of-the art.
Both the proposed methods for Human Reliability Analysis have been tested on the maintenance activities performed by qualified operators nearby the railroad. The results highlight the significant contributions of the human error within the contexts of the complete risk assessment of the railway system.
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Yao, TsungTing, i 姚宗廷. "Optimal Production and Inspection Strategy of Imperfect Rework, Inspection Time and Maintenance Error". Thesis, 2011. http://ndltd.ncl.edu.tw/handle/64952615804884204201.
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碩士東南科技大學
工業管理研究所
99
This paper proposes an optimal policy which integrates production, inspection, maintenance, inspection time and inventory problem to consider imperfect rework and maintenance error are allowed for an imperfect production process. We find the optimal inspection interval, the expected number of inspection and economic production quantity of the maximum expected profit per unit. The production process may turn into “out-of-control” state from “in-control” state because of the human behavior or the machines. If the production process is “in-control” state, we execute preventive maintenance, system age is related to the level of preventive maintenance. When the production process is “out-of-control” state, some defective items are produced. Assuming some of the defective items can be reworked and turn to well item, others can not be reworked and turn to waste item. In conclusion, we investigate the benefit of the preventive maintenance in the deteriorated system of the production process. Numerical examples illustrate the effect of preventive maintenance level, imperfect rework, inspection time and maintenance error on the expected profit per unit.
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Chuan, Wen, i 劉文全. "Risk Perception and Risk Propensity Affect Human Error factors of Aircraft Maintenance -Case Study". Thesis, 2005. http://ndltd.ncl.edu.tw/handle/98978461370471800217.
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碩士國立中正大學
勞工所
93
Abstract Subject：Risk Perception and Risk Propensity Affect Human Error factors of Aircraft Maintenance -Case Study Student：Wen Chuan Liu Aviation Safety is always the ongoing goal to human's flight activities, however, air crash is for a variety of reasons which includes: the design and manufacture of an airplane, the maintenance schedule, the weather, the Air Traffic Control factor and pilot's operation process as well as the organization culture and decision making of the Civil Aviation Authority or of the Air Lines. The "Human" Error Factor that could be prior prevented or could be an avoidable mistake is widely involved in complicated operation process or just has been in the environment. Reasonable decision makers assume that we humans are reasonable and objective and will certainly make decision between the biggest benefit and the smallest loss. However, the school of behavior found out through empirical research (Kahneman & Tversky, 1979) that we humans just won't make decision base on a reasonable, objective or econometric way to search for their final goal but to make decision through person preferences. Risk means the uncertainty of life and with an outcome to influence human life; risk focuses on future possibility and future uncertainty. Therefore, main purpose of this research is to discuss how the different Risk Perception and Risk Propensity from maintenance crew can influence the factor of Human Error. In summary, this research discovers that: (1) Other than education element of population variable, there is also with great difference to Risk Propensity among different genders, organizations, departments, ages and numbers of years in employment. (2)There's no big difference between the degree of familiarity and Risk Perception, and an inverse correlation between organizational control and Risk Perception; Risk perception, Risk Propensity and Human Error are all in positive correlation. (3) There is obvious difference of Risk Perception between High/Low degree of familiarity or High/Low degree of organizational control from/to maintenance crew. (4) There is obvious difference of Human Error between High/Low degree of Risk perception or High/Low degree of Risk Propensity from maintenance crew. (5) Risk Perception will not influence Human Error by the interference of Risk Propensity. (6) The degree of familiarity and organizational control can predict and explain Risk Perception. (7) Risk Perception and Risk Propensity can predict and explain Human Error. Key Words: Familiarity, Organizational Control, Risk Perception, Risk Propensity, Human Error
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TU, JIONG-YU, i 凃炯宇. "Establishment and Application of a Latent Error Factor Analysis Method for Aviation Maintenance Task". Thesis, 2014. http://ndltd.ncl.edu.tw/handle/b4j8hk.
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碩士國立清華大學
工業工程與工程管理學系
102
Today, although many works can be replaced by machines, the maintenance tasks still rely on people with unexpected mistakes at the same time. Usually the causes of these mistakes are due to a sequence of errors; however, if only reviewed the direct active errors without further investigation of indirect latent errors, the similar accident may happen again. In this study, an analysis method is developed to find out the most important latent human error factor. By using Root Cause Analysis (RCA) method as the basic logic, Human Factor Analysis and Classification System (HFACS) as the factor source and daily check of aviation maintenance as a case study, this research dismantled the maintenance process and collected the data of each procedure. After designing the questionnaire by the preliminary factors and surveyed 115 experienced maintenance operators to do the analysis, the importance ranking of factors allows the airline to specifically design improvement plans directly, and the reference values have also been set for the use to related researches. Here comes some sum up of conclusions in this study. First, the most important active factor is “Task execution error”, and the latent factor which has the most influence is “Maintenance capability.” Second, the combination of RCA and HFACS is an easy use method to investigate the causal inference and build the factor connection of collected data. Third, the research outcomes suggested not only the results caused by latent errors and the improvement direction, but the priorities for the improvement and the reference values of each active error factor to each step.
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Nkosi, Mfundo S. "A study into the effect of human error on substandard maintenance performance, and the formulation of a complete solution based on the experience of successful maintenance organisations". Thesis, 2015. http://hdl.handle.net/10210/14975.
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M.Phil. (Mechanical Engineering)The coal mining industry plays a major role in the global economy. Coal is required for the provision of primary energy needs, generation of electricity and production of steel. Hence, there is a high demand of coal worldwide. For the continuous supply of coal, mining equipment should be in good working conditions and the maintenance teams should be highly equipped and motivated to perform their maintenance activities ...
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Hsiang-Long, Chao, i 趙湘龍. "A Study for Maintenance Human Error and the Causes in T.F.W. of the R.O.C. Air Force". Thesis, 2005. http://ndltd.ncl.edu.tw/handle/13380786679980834473.
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碩士國防管理學院
後勤管理研究所
93
As we know, the work contents of flight safety are inclusive of everything, we can subdivide these three major accomplish causes classification: human error, environment （atmosphere）factor and mechanical （maintenance）factor which made the accident events happened into seven causes: crews, aviation control, meteorological phenomena, station management, navigational matters operation of the aviation company, the function of the airplane and maintenance, as reviewed those severe events and death accidents which happened during 1959-1996 in international civilian aviation scope, we could analysis and had this conclusion which human error occupied 73.3% among total events, consequently, human error is the most major reason of the airplane accident. First step of this research was collected the primary statistical materials of flight safety events from ROCAF, and proceeded analysis at flight safety events classification and the beginning cause of accident to realize the relationship between each flight event which occurred nearly several years in ROCAF; besides this there is an open-up questionary which made basically according to 12 causes which possessed potential possibility of human error on aircraft maintenance brought up by Canada Transportation Department, and joined with 4 questions about the application situation of the ROCARE, offered to the technician in T.F.W. of the ROCAF to carry out questionary investigation of the human factor which might cause human error and the application effect of ROCARE, in order to evaluate the difference concerned about among different technician types in T.F.W. of the ROCAF for the cause of technician mistake. This research took the technician whom working in T.F.W as the object of study, the effective retrieved rate for the questionary is 89.02%, totally about 527 persons whom had been sieved out as the research sample, through various statistics and analysis method to examine and analyze these retrieved questionary, we finally got the conclusion as follows: 1.There are obvious differences among each grade of the dangerous flight events and their causes, the mistake made by the pilot was the first reason inside of these causes which we found in the first, second and third grade events, but for the fourth grade events the major cause is mechanism factor. Analyzing the amount for each grade of dangerous flight events according to the human factor, it was found that there is no obvious difference for the amount between airman errors and technician errors, but the error rate for airman and technician became different according to the different grade of dangerous flight events, the pilot error is higher than the technician errors in the first, second and third grade events. And the technician errors in the fourth grade events, it was found that the unit which performing direct maintenance made more errors than the unit which performing indirect maintenance. And for the unit which performing direct maintenance, it was found that I/L maintenance unit made the most errors, the on-line unit and performing unit was less than, and for the cyclic-check unit was more less than. 2.The common point of view at the main reasons which causes human error made by ROCAF technician were fatigue, complacency, lake of awareness, pressure and lake of professional knowledge. Technicians also have difference according to their group characteristic as their age, marriage, job, working seniority, safety training, rank, military educational background and etc. 3.Nearly 50% technician aware of ROCARE which established by the ROCAF, but less than 10% of them had ever used this system; And nearly 50% of them think this Active Flight Safety Reporting System can help the prevention of maintenance error and improving the aviation safety, but there are only 30% of them who will trust that the Active Flight Safety Reporting System can make these targets as: keeping secret, free of responsibility, neutral, trustworthy, professional. It conveys that technician aware of the existence of this system and trust it’s function of helping to prevent maintenance error and to improve the aviation safety, but they don’t think the establishment unit can do the good job at some measures as keeping personal information secret and etc., not even share their personal experiences.
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Islam, TMR. "Human reliability assessments for the maintenance operation of marine systems". Thesis, 2017. https://eprints.utas.edu.au/23790/7/Islam_whole_thesis_ex_pub_mat.pdf.
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Human intervention plays a critical role in the maintenance operations of marine systems. Consequently human factors are identified as one of the main causes of accidents in marine systems especially during maintenance operations. Characterisation and assessments of human factors in the form of Human Reliability Assessment (HRA) is an important step to better understand accident causation during maintenance operations. This would help minimize human errors and enhance overall safety and reliability of the marine systems. The International Maritime Organization (IMO) recommends implementing HRA to quantitatively assess the effect of human errors as a part of quantitative risk analysis of shipping operations. However, HRA for the maintenance operations of marine systems is not given due attention. This PhD research is focused on developing novel methodologies to accurately estimate the Human Error Probability (HEP) during the maintenance operations of marine systems. The developed methodologies will help in better understanding accident causation, estimation of HEPs, and to develop the required strategies to minimize the HEP.
This thesis contains seven chapters. The first chapter provides the introduction and general structure of the thesis. Second chapter presents development of a novel methodology to assess the HEP for the maintenance operation of marine systems. The developed methodology is applied to the maintenance procedures of a marine engine as a case study. The results showed that among the 43 considered activities, ‘inspection and overhaul of piston/piston rings’ have the lowest HEP meaning it has a low consequence for accidents. On the other hand, ‘fuel and lubricating oil filters pressure difference checking’ and ‘renew filter element’s activity have the highest HEP indicating it has highest chances of accidents. The third chapter presents a novel monograph as an easy-to-use tool to estimate HEP for marine operations. The developed monograph is applied to the maintenance procedures of a High Pressure (HP) fuel pump for estimating HEP. The results showed that ‘inspection of fuel injectors’, ‘renewing nozzles’ and ‘testing’ has the highest HEP. While the fourth chapter proposes a novel technique by revising and modifying the Human Error Assessment and Reduction Technique (HEART) to assess the HEP during the maintenance activities in marine operations. The developed methodology is applied to the maintenance procedures of a marine engine exhaust turbocharger as a case study. Application of the developed methodology confirms that extreme weather condition, extreme workplace temperature, high ship motion, high level of noise and vibration, and work overload and stress all increase the likelihood of human error as well as likelihood of potential accidents. The fifth chapter presents development of an HEP assessment technique using an advanced probabilistic technique named Bayesian Network (BN). The developed methodology is tested on the maintenance of marine engine’s cooling water pump for engine department and anchor windlass for deck department. The case study results showed that category “A” chief engineer/captain (highest rank) with 10 years or more experience and voyage duration of 1 month has the lowest HEP, and category “D” fourth engineer/third officer with 5 years’ experience and voyage duration of 4 months has the highest HEPs. As part of the HRA, extensive data collection activity was conducted. The details of this activity and outcome are reported in this thesis. The collected data is analysed for normality and also pair-wise significance test and presented in chapter 6. It helps to study generalization of the data and also to identify the relative importance of the factors. Workload and stress, and ship motion (roll and pitch) are identified to be critical factors affecting human performance on on-board maintenance operations. The collected data played an important role in testing and verifying earlier developed techniques and models. Chapter 7 includes the conclusions of the thesis.
This thesis aims to serve as a comprehensive source of knowledge and technique to form a better understanding of human factors associated with maintenance activities in marine operations. It will assist in ensuring implementation of IMO requirement for safe and reliable maintenance activities and marine operations.
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Hu, Che-Chang, i 胡哲彰. "Assessing The Effect of Human Error and the Shutdown Risk in Nuclear Power Plant for On-line Maintenance". Thesis, 1998. http://ndltd.ncl.edu.tw/handle/97423445376003162395.
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Ling, Hsu Fang, i 許芳玲. "The Research on the Training and Human Error of the Operating and Maintenance Personnel of the Thermal Power Station of Taiwan Comany". Thesis, 1994. http://ndltd.ncl.edu.tw/handle/82666111152593296036.
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Chiu, Shin-yi, i 邱信誼. "Investigation of the Key Factors of Human Error with Multicriteria Analysis - Case study of the Maintenanse System for Landing Gear,Flight Operators and Engine". Thesis, 2011. http://ndltd.ncl.edu.tw/handle/wgqfpm.
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碩士國立高雄第一科技大學
機械與自動化工程研究所
99
The study of human error in maintenance of the impact of Air Force aircraft, and landing gear systems, flight operations department and maintenance of the engine system operators is analyzed, the questionnaire structure is the core concept SHELL mode, the reason for classification of human error induced for the LS (people to software), LH (people to hardware), LE (people to the environment), L (of their own limitations), LL (people to people) in five dimensions and the layer is divided into 17 criteria, the use of multi-criteria decision analysis theory of AHP, CRITIC method, the standard deviation method and Grey method were seeking their weights, the weight of AHP by subjective analysis and found that the major factor inducing human error is the whole L (of their own restrictions) in the first place, which replaced the "staff of the psychological state of" maximum value for the weights, showing that psychological adjustment to staff the root causes of human errors induced. Supplemented by the objective weight CRITIC method, the standard deviation method and the weight of ash analysis of the implementation of related laws, there is a significant causal relationship exists, the gray relational method is obtained by "lack of equipment or hand tools," the first sort, showing that a lack of equipment, a great impact, maintenance staff to achieve the task, as must use non-standard hand tools to perform the repair, which will indirectly causing psychological stress, inconsistent with hand tools to perform the repair, construction quality be compromised, resulting in more effective, even derivative accident unfortunate.
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Virtuoso, Maria Manuela Vicente. "A fadiga no contexto das operações de manutenção de aeronaves (um estudo envolvendo empresas de manutenção em Portugal continental)". Master's thesis, 2020. http://hdl.handle.net/10437/11560.
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Orientação: Anabela dos Santos Aleixo SimõesO presente trabalho centra-se no estudo das condições técnicas e organizacionais em que se realizam as operações de manutenção de aeronaves na aviação civil, em Portugal continental, bem como nos efeitos dessas condições sobre as capacidades funcionais e sobre o desempenho dos técnicos de manutenção. Serão analisados os vários tipos de fadiga, como eles se instalam, os constrangimentos introduzidos pelo trabalho noturno, quais os erros mais comuns que daí resultam e quais os fatores que mais condicionam o desempenho dos técnicos nestes ambientes, que são caracterizadamente complexos. A partir desse estudo base, pretende-se determinar qual o contributo da fadiga (física e mental) e da organização do trabalho para a ocorrência de erros e quais os riscos daí decorrentes no que se refere às condições de segurança dos próprios trabalhadores da manutenção e, indiretamente, dos passageiros das aeronaves. São também abordados os aspetos relacionados com formação e treino e a sua importância e impacto na indução de stress nos técnicos de manutenção de aeronaves. Por último, será ainda analisado em que medida a vulnerabilidade relativamente à fadiga e ao stress apresenta diferenças significativas em função: (1) da antiguidade: afetam mais as pessoas com maior antiguidade e menos as pessoas com menor antiguidade? (2) da idade: afetam mais as pessoas mais velhas do que as mais novas? De modo a responder às questões de investigação e procurar a existência de sintomas de fadiga entre os Técnicos de Manutenção de Aeronaves (TMA), foi disponibilizado, via Internet, um questionário individual e anónimo, quer relativamente a cada sujeito, quer relativamente à empresa onde o TMA trabalha. Foram abordadas 15 empresas que prestam serviços de manutenção a aeronaves em Portugal continental. O questionário teve 55 respostas, que foram a base do trabalho apresentado.
This paper focuses on the study of the technical and organizational conditions under which aircraft maintenance operations are carried out in civil aviation in mainland Portugal, as well as the effects of these conditions on the functional capabilities and performance of maintenance technicians. The various types of fatigue will be analyzed, how they settle, the constraints introduced by night work, what are the most common errors that result and which factors most affect the performance of technicians in these environments, which are characteristically complex. From this study, it is intended to determine the contribution of fatigue (physical and mental) and work organization to the occurrence of errors and the resulting risks regarding safety conditions of the maintenance workers themselves and, indirectly, of aircraft passengers. The training aspects and it importance and impact on stress induction in aircraft maintenance technicians are also addressed. Finally, it will also be analyzed to what extent vulnerability to fatigue and stress presents significant differences as a function of: (1) Seniority in the job: how it affects technicians? (2) Age: how it affects technicians? In order to answer the research questions and look for the existence of fatigue symptoms among Aircraft Maintenance Technicians (AMT), an individual and anonymous questionnaire was made available via the Internet, both for each subject and for the company where the AMT works. 15 companies that provide aircraft maintenance services in mainland Portugal were approached. The questionnaire had 55 responses, which were the basis of the work presented.
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Jean, Dar-Fu, i 簡達夫. "THE IMPLICATION OF ORGANIZATIONAL LEARNING IN THE PREVENTION STRATEGY OF HUMAN ERROR--TAKE THE OPERATION/MAINTENANCE DEPARTMENT OF NUCLEAR POWER PLANT OF TAIWAN POWER COMPANY AS EXAMPLE". Thesis, 1999. http://ndltd.ncl.edu.tw/handle/23981746156439331642.
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碩士國立交通大學
經營管理研究所
87
ABSTRACTS The abnormal incident happened in last few years in the nuclear power plant of Taiwan power company had been major report subject of the press, accumulated incident happened in previous years, there was phenomena of reoccurrence in several cases. We discuss the cause subject to these phenomena are main defect of the existing human prevention strategy. The cause of these defect was due to the deficiency or incorrect of technical recognition of the personnel work under uncertain situation. This study subject to the limited learning resulting from deficiency of existing prevention strategy and try to seek a reasonable resolution based on the view of organization learning. First we discuss according to the characteristic of existing prevention strategy and its defect, understand and categorize respectively to the assumption of the key factors of each existing prevention strategy, and analyze the effective characteristic of each model of the resolution of reoccurrence provided by organization learning one by one, finally raise the feasible increment effect subject to all human error prevention strategy respectively according to the characteristic of these model, these are the implication of the organizational learning in prevention strategy of human error. Proving by the case example, this consequent is feasible in practice application, and found that a effective prevention strategy in addition to characteristic of synthesis, it possess mechanism of unfreezing, change, freezing as well. The purpose of the existence of these mechanism in the organization learning which serve as human error prevention strategy are no more than maintaining the weltanschauung (World View) of the mental model of the action client and the organization, response to the environment effectively and correctly, and prevent the reoccurrence of the human error.