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Root Cause Analysis of Human Errors in Complex System Accdidehts

Research Project

Project/Area Number 12680441
Research Category

Grant-in-Aid for Scientific Research (C)

Allocation TypeSingle-year Grants
Section一般
Research Field 社会システム工学
Research InstitutionKYOTO UNIVERSITY

Principal Investigator

INOUE Koichi  Kyoto University, Graduate School of Engineering, Professor, 工学研究科, 教授 (70026079)

Co-Investigator(Kenkyū-buntansha) KOHDA Takehisa  Kyoto University, Graduate School of Engineering, Associate Professor, 工学研究科, 助教授 (60205333)
Project Period (FY) 2000 – 2001
Project Status Completed (Fiscal Year 2001)
Budget Amount *help
¥3,200,000 (Direct Cost: ¥3,200,000)
Fiscal Year 2001: ¥1,300,000 (Direct Cost: ¥1,300,000)
Fiscal Year 2000: ¥1,900,000 (Direct Cost: ¥1,900,000)
KeywordsComplex System Accidents / Human Errors / Root Cause / Mental Images / Error Classification Rule / Component Failure / Situation Awareness / Action Generation
Research Abstract

The object of this research is to establish a method to identify root causes of a system accident using the knowledge on human errors obtained in human factors, and cognitive engineering etc.
At the first stage in Heisei 12, a framework was considered to identify root causes of human errors and component failure. To estimate the human cognitive process, a concept of 'mental images (MI)' was applied. From the viewpoint of how to recognize situations (generation of MI), how to make a decision on what to do (action planning based on MI), and how to act (execution based on MI), errors are identified as deviations from the desired criterion. Application to marine accidents showed that root causes were obtained and the merits of the method were confirmed. Further, as the situation awareness was essential, how to allocate monitoring points was derived to identify the system state. Related to system state identification, how to evaluate the effect of a potential component failure on the system function was also considered.
In the second stage in Heisei 13, the analysis method to identify root causes of human errors was improved, and further problems to be solved were clarified. Based on MI, the surface human errors were classified into errors in acquisition of input information, errors in judgment, and errors in action execution, Based on MI formation from input imformation sources, the framework was improved to identify root causes of each type of errors. By applying the proposed method to a ship accident, its merits were confirmed. Further, a derivation method of accident sequences was proposed to consider safety measures to prevent accidents in a complex system. The method is based on a global system model composed of hardware behavior such as components, software behavior such as computerized actions, and human actions.

Report

(3 results)
  • 2001 Annual Research Report   Final Research Report Summary
  • 2000 Annual Research Report
  • Research Products

    (36 results)

All Other

All Publications (36 results)

  • [Publications] Takehisa Kohda: "Detectability and Identifiability of Safety Monitoring Systems"Foresight and Precaution (Ed. by M.P.Cottam et al.). Vol.2. 1589-1594 (2000)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Yoshihiko Nojiri: "Operator's Action Generating Process Considering Prediction Activity"Proc. Of Cognitive System Engineering in Process Control 2000. 44-51 (2000)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Takehisa Kohda: "Root Cause Analysis of JCO Accident Based on Decision-Making Model"PSAM5 -Probabilistic Safety Assessment and Management (Ed. by S.Kondo & K.Furuta). Vol.3/4. 1995-2000 (2000)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] 野尻 良彦: "プラントオペレータの情報収集と行為生成"第33回安全工学研究発表講演予稿集. (2000)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Takehisa Kohda: "Fault-Tree Analysis Considering Latency of Basic Events"2001 Proc. -Annual Reliability and Maintainability Symp.. 32-35 (2001)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] 吉田 倫生: "故障診断のための監視項目選定法に関する一考察"第5回「信頼性とシステム安全学」予稿集. 26-33 (2001)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] 野尻 良彦: "認知メカニズムとヒューマンエラー解析"日本信頼性学会誌. 23巻・2号. 157-166 (2001)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] 野尻 良彦: "メンタルイメージに基づくプラントオペレータの会話分析"ヒューマンインターフェースシンポジウム2001論文集. 515-518 (2001)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] 幸田 武久: "ヒューマンインターフェース技術とシステム安全・信頼性設計"ヒューマンインターフェースシンポジウム2001論文集. 539-540 (2001)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] 幸田 武久: "統合システム挙動モデルに基づくシステム安全対策の構築"第34回安全工学研究会発表講演予稿集. 129-132 (2001)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Yoshihiko Nojiri: "Identification of Human Error Causes Based on Formation of Mental Images"Proc. Asia Pacific Symposium on Safety APSS2001. Vol.2. 111-114 (2001)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] 幸田 武久: "システム安全設計について"第6回「信頼性とシステム安全学」予稿集. 70(1)-70(4) (2002)

    • Description
      「研究成果報告書概要(和文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Takehisa Kohda and Koichi Inoue: "Detectability and Identifiability of Safety Monitoring Systems"Foresight and Precaution (Ed. by M.P. Cottam et al). Vol. 2. 1589-1594 (2000)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Yoshihiko Nojiri, Takehisa Kohda and Koichi Inoue: "Operator's Action Generating Process Considering Prediction Activity"Proc, of Cognitive System Engineering in Process Control 2000. 44-51 (2000)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Takehisa Kohda and Koichi Inoue: "Root Cause Analysis of JCO Accidents Based on Decision-Making Model"PSAM5 - Probabilistic Safety Assessment and Management (Ed. by S. Kondo & K. Furuta). Vol. 3/4. 1995-2000 (2000)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Yoshihiko Nojiri, Takehisa Kohda and Koichi Inoue: "Plant Operator's Information Acquisition and Action Generation"Proc. 33^<rd> Symposium on Safety Engineering. (in Japanese). 89-92

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Takehisa Kohda and Koichi Inoue: "Fault Tree Analysis Considering Latency of Basic Events"2001 Proc. Annual Reliability and Maintainability Symp.. 32-35 (2001)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Michio Yoshida, Takehisa Kohda and Koichi Inoue: "Consideration of Allocation of Monitoring Points for Failure Diagnosis"Proc. 5^<th> Reliability and System Safety. (in Japanese). 26-32 (2001)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Yoshihiko Nojiri, Takehisa Kohda and Koichi Inoue: "Cognitive Mechanism and Human Error Analysis"Journal of Reliability Engineering Asssociation of Japan. Vol. 23, No. 2 (in Japanese). 157-166 (2001)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Yoshihiko Nojiri, Takehisa Kohda, Koichi Inoue and Fumio Tanaka: "Analysis of Plant Operator's Communication Based on Mental Image"Proc. Human Interface Symp. 2001. (in Japanese). 515-518 (2001)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Takehisa Kohda and Koichi Inoue: "Role of Human Interface Technology in Systems Safety/Reliability Design"Proc. Human Interface Symp. 2001. (in Japanese). 539-540 (2001)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Takehisa Kohda and Koichi Inoue: "Design of System Safety Actions Based on Global System Behavior Model"Proc. 34^<th> Symposium on Safety Engineering. (in Japanese). 129-132 (2001)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Yoshihiko Nojiri, Takehisa Kohda and Koichi Inoue: "Identification of Human Error Causes Based on Formation of Mental Images"Proc. Asia Pacific Symposium on Safety APSS2001. Vol. 2. 111-114 (2001)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] Takehisa Kohda and Koichi Inoue: "On System Safety Design"Proc. 6^<th> Reliability and System Safety. (in Japanese). 70(1)-70(4) (2002)

    • Description
      「研究成果報告書概要(欧文)」より
    • Related Report
      2001 Final Research Report Summary
  • [Publications] 野尻 良彦: "認知メカニズムとヒューマンエラー解析"日本信頼性学会誌. 23巻・2号. 157-166 (2001)

    • Related Report
      2001 Annual Research Report
  • [Publications] 野尻 良彦: "メンタルイメージに基づくプラントオペレータの会話分析"ヒューマンインタフェースシンポジウム2001論文集. 515-518 (2001)

    • Related Report
      2001 Annual Research Report
  • [Publications] 幸田 武久: "ヒューマンインタフェース技術とシステム安全・信頼性設計"ヒューマンインタフェースシンポジウム2001論文集. 539-540 (2001)

    • Related Report
      2001 Annual Research Report
  • [Publications] 幸田 武久: "統合システム挙動モデルに基づくシステム安全対策の構築"第34回安全工学研究発表会講演予稿集. 129-132 (2001)

    • Related Report
      2001 Annual Research Report
  • [Publications] Yoshihiko Nojiri: "Identification of Human Error Causes Based on Formation of Metal Images"Proc. Asia Pacific Symposium on Safety APSS2001. Vol.2. 111-114 (2001)

    • Related Report
      2001 Annual Research Report
  • [Publications] 幸田 武久: "システム安全設計について"第6回「信頼性とシステム安全学」予稿集. 70(1)-70(4) (2002)

    • Related Report
      2001 Annual Research Report
  • [Publications] Yoshihiko Nojiri: "Operator's Action Generating Process Considering Prediction Activity"Proc.of Cognitive System Engineering in Process Control 2000. 44-51 (2000)

    • Related Report
      2000 Annual Research Report
  • [Publications] Takehisa Kohda: "Detectability and Identifiability of Safety Monitoring Systems"Foresight and Precaution (Ed.by M.P.Cottam et al.). Vol.2. 1589-1594 (2000)

    • Related Report
      2000 Annual Research Report
  • [Publications] Takehisa Kohda: "Fault-Tree Analysis Considering Latency of Basic Events"2001 Proc.-Annual Reliability and Maintainability Symp.. 32-35 (2001)

    • Related Report
      2000 Annual Research Report
  • [Publications] Takehisa Kohda: "Root Cause Analysis of JCO Accident Based on Decision-Making Model"PSAM5-Probabilistic Safety Assessment and Management (Ed.by S.Kondo & K.Furuta). Vol.3/4. 1995-2000 (2000)

    • Related Report
      2000 Annual Research Report
  • [Publications] 野尻良彦: "プラントオペレータの情報収集と行為生成"第33回安全工学研究発表講演予稿集. 89-92 (2000)

    • Related Report
      2000 Annual Research Report
  • [Publications] 吉田倫生: "故障診断のための監視項目選定法に関する一考察"第5回「信頼性とシステム安全学」予稿集. 26-33 (2001)

    • Related Report
      2000 Annual Research Report

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Published: 2000-04-01   Modified: 2016-04-21  

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