The Application of the Root Causes of Human Error Analysis Method Based on HAZOP Analysis in Using Process of Weapon

摘要

Cognitive Reliability and Error Analysis Method (CREAM) is one of the most representative secondgeneration human reliability analysis methods.By using the CREAM, the retrospective analysis of the root causes of human error is given. There are no accordant standards of the determination of event sequences caused by the human errors in the root causes analysis in using process of weapon in CREAM.This paper presents the root causes of human error analysis method based on HAZOP analysis hi using process of weapon.And according to the deficiency of CREAM, the improvement measures are put forwards as follows: (1) According to the HAZOP method,using process of the weapon is divided into parts according to the different operation steps.And the operation by human is defined as the characteristic parameters;(2) According to the deviations analysis, the event-order diagram should be achieved based on the correct operation steps and the deviations.Using the improved method, the event sequence which is end in failure and caused by human error can be gained.After choosing the human error event, the root causes can be obtained by retrospective analysis.An example of diesel engine underwater starting is discussed in this paper.And the root causes of human error leading to water intake are obtained.This example validates the correctness of the unproved method in this paper.