報告書番号

Y09017

タイトル（和文）

ヒューマンファクター事象分析に基づくルール逸脱実態把握法の検討

タイトル（英文）

A study on method to identify actual causes and conditions of safety rule deviations through analyzing events due to unsafe acts of workers

概要 （図表や脚注は「報告書全文」に掲載しております）

本研究の目的は、ヒューマンファクター事象分析に基づき、事業所におけるルール逸脱の実態把握および実効的な対策立案を実現する手法を構築することである。まず、先行研究および当所の知見を整理した結果、ヒューマンファクター事象分析に基づくルール逸脱実態把握の利点として、①ルール逸脱とヒューマンエラー・事象発生の関係を明確化できる、②ルール逸脱の意識的な選択に至った背景にある関係者の行為、ルール自体の問題、設備・環境条件、管理等の様々な要因や、その因果関係を具体的に示せる、を抽出した。次に、この利点を踏まえて、複数の業界の事象データを対象に、ルール逸脱実態把握のためのヒューマンファクター事象の試行的分析を行った。その結果、上記利点を最大限活かすための要件（情報収集時の行為の拠り所となるルールの有無、および、そのルールの意識的な選択の有無、その選択の背景にある要因の明確化など）を明らかにした。

概要 （英文）

The purpose of this study is to establish a method to understand actual causes and condition of intentional deviation from safety rules(including norm and written rules that has developed to anticipate, prevent, detect and recover human errors) in an organization by analyzing events due to unsafe acts of workers (human factor events) and to propose effective measures.
Firstly, by reviewing literature regarding safety violations, the following two advantages of investigating actual condition of safety rule deviation through human factor event analysis were extracted, such as (a) being able to clarify relationships between deviations, human errors, and events, and (b) being able to identify specific causal factors that influenced the decision to deviate, including acts of people concerned, problems with rules, task demands, environment and management. Next, through the trial analysis of human factor event data in accordance with existing human error analysis method on the basis of advantages above, the following three requirements for analyzing event data were extracted, such as (a) gathering information such as rules concerning to the work activities related to the human factor events, and whether there are intentional deviations of the rules, (b) gathering information and identify interrelations among causal factors of the intentional deviations, and (c) general condition of deviations and the causal factors.

報告者

キーワード