ヒューマンエラーを考察したリスクアセスメント手法の研究
Contents
1. 9 112. G
3. RECARO BA 4 MIL STD 882C 1993029 DIN V 19250 199409 BS5304 1988
4. RETA 3 5
5. Tao Fg ge HAE 10 6 HE 6 4 2 1 3 4 HARE 3 2 1 4 2 1 10 1 1 2 IV Figure 10 Risk assessment work sheet for pullman loaf slicer 1 of 2 I II I 20 24 13 19 TD 6 Hold to run R A
6. 8 Figure 8 Worker scraping out meat from mixing machine 9 10 11 12 Aik 6
7. PSF 4 1 O A K 5 MIL STD 882C 1993
8. R P OFA ERRENA O BRED BSABME A P f E O A ENAS 2 D o R ORL R F C P f C E O A 3 GER 9 7 3 4 9
9. 1 No 1 2 3 REO JALE PSF BINS CISA TT IVC ATA AIC ee Cay 20cm
10. 5 Hold to run 10 BO Figure 10 Risk assessment work sheet for pullman loaf slicer 2 of 2 Figure 11 PSF evaluation sheet for meat mixing machine PSF 1 1213 1415 16 7 9 101 F nw an z A ie gt Qo He lo gt Qo SO OS 00k 3 De
11. 5 G96G2 OO O
12. Risk assessment tools incorporating human error Tetsu Moriyama and Hideo Ohtani National University of Yokohama Though Risk Assessment tools incorporating human related aspects is highly required for general industry people it has been reported that as many as 80 of all occupational accidents have human errors as a cause Human error probability HEP has been used for large scale safety critical industries for last quarter century but these tools are not suitable for more general industries that comprise the majority of occupational accident settings Here we describe and verify a risk assessment tool that includes human related aspects for general industries The tool expands on traditional risk assessment methods such as matrix risk graph and numerical scoring method by adding human related aspects The tool is easy to use fast and requires low resources in general occupational environments and includes assessments of human behavior and potentially outdated machinery at work place and small companies PSF 1 80 oe OOO
13. 4 PSF 3 5 PSF HRP 102 104 PSF OS Swaim 1983 Gertman 9 8 PSF HEP 5x101 105 six nine
14. 10 000 6G2 5 Table 5 Suggested mishap probabilities levels A FREQUENT X gt 101 B PROBABLE 101 gt X gt 102 C OCCASIONAL 102 gt X gt 103 D REMOTE 103 gt X gt 106 E IMPROBABLE 106 gt X 5 A FREQUENT B PROBABLE OCCASIONAL 101 102 103 D A B PSF 8 HEP PSF 8 HEP 1 0 5 4 2 MIL STD 882C Q998 5 CEDULE ZANNI E LE 2 ANSI B11 TR3 4x4 8x8
15. 4 No RA No
16. P Personal Protective Equipment PPE A 2 2 1 HRP 1 HEP E HEP J PSF
17. WS 2
18. ARTA PREP SILENT CHES FE FRR ARIEL RB 9 10 11 0 1 2 3 PSF 1 4 5 6 PSF 2 7 8 9 10 PSF 11 Figure 11 PSF evaluation sheet for meat mixing machine
19. i 1 0 10 1 1 0 9 3 7 3 4 RA Table 4 Redefinition of risk assessment elements s tr nn 7 ss 2 9 f JA eS of l wis Z eee ee tm be E BEEK
20. PSF 8 10 TOR PSF 1 17 2 ISO 2003 ISO 12100 1 Safety of machinery Basic concepts general principles for design Part 1 Basic terminology methodology 3 ISO 2003 ISO 12100 2 Safety of machinery Basic concepts general principles for design Part 2 Technical principles 4 ISO 1999 ISO 14121 Safety of machinery Principles of risk assessment 5 18 3 10 0310001 6 Swain A D and H E Guttmann 1983 Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications NUREG CR 1278 7 1996 1
21. BEEP SIVAN CHB 7E 9 10 11 ae aoe ly ERS ae oe DE ae ely O O A B C D GE P PSF 12 1 2 Figure 12 Risk assessment work sheet for meat mixing machine 1 of 2
22. PSF 1 2 8 PSF 3 4 Z PS Table 7 Risk index and PSF level for risk estimation ANSI PSF PSF PSF B11 TR3 1 2 3 16 High 5 A 15 High 14 High A 13 High 12 High 11 Medium 10 Medium 9 Medium 8 Medium 7 Low 6 Low 5 Low 4 Low 3 Negligible 2 Negligible 1 Negligible 4 83 DIN V 19250d9 4 ERR CORRA Z 2 G 2 W 3 W1 W2 W3 PSF 1 2 3 W1 W2 W3 5 7245S A G W
23. PSF 1 8 15 8 ISO 2007 ISO14121 1 2007 Safety of machinery Risk assessment 9 ISO 2007 ISO TR14121 2 2007 Safety of machinery Risk assessment Part 2 Practical guidance and examples of methods 10 Gertman D H Blackman et al 2005 The SPAR H Human Reliability Analysis Method NUREG CR 6883 11 1990 12 US Department of defense 1993 MIL STD 882C System Safety Program Requirement 13 American National Standards Institute 2000 ANSI B11 TR3 2000 ANSI Technical Report for Machine Tools Risk assessment and risk reduction A guide to estimate evaluate and reduce risk associated with machine tools 14 DIN V 19250 1994 Basis safety evaluation of measuring and control protective equipment 15 and 005 OO 10 16 and 2005 PSF fies Vol 9QNo 2 9 17 a
24. PSF 3 3 A 1 Gdentifcation LS
25. ORM P A PPE 1 Figure 1 Occupational accident flow 2 3 Y 3 5 FF
26. K 3 PSF 1 0 1 3 3 1 3 2 18 1 3 2 1 PSF 3 PSF 2 PSF 1 SEKTA 3 4
27. 8 3 0 001 _ 4 0008 3 1 Sn eee 0 01 oe 2 Lace a _ wi t anions i f 7 7 0 003 BADORRZ amp SIE TH GA SILGED A aaa S 7 8 N BS 0 003 CORSAIR LTOS RER 9 0 01 10 0 001 x 3 2 PSE 2 2 PSF fil Table 2 PSF during slicing work oneness eeseeeeseseeeeeseesesessseeeseeseeeesesesseseseseesesesesseseseeecseseseesese
28. K 6 5x4 20 4x4 16 3x3 9 20 16 3 High Medium RO Table 6 Risk estimation matrix P 10 gt X gt 10710 gt X gt 10 7 10 gt X gt 10 1 1 MIL STD 882C 2 16 3 ANSI B11 TR3 ANSI B11 TR3 2000 TENUES 4 PSF 3 Figure 4 PSF levels and associated e matrices Low 4 High risk Medium risk Moderate risk Low risk QR 7 4 ANSI B11 TR3
29. SWAIN Q9839 Table 20 2 Table 3 2 HFC 2 1 2 3 8 9 HEP ITY VES EEA L UC PSF A 1 HEP PSF PSF 1 Table 1 Sharpen slicer disk saw interruption and HEP No HP 1 2 PSF 1 PSF
30. 12 2 2 Figure 12 Risk assessment work sheet for meat mixing machine 2 of 2
31. H No No ON 0OFF 2 Hold to run 5 Hold to run
32. PSF Greater human error probability 1 0 Stronger error causing effect of the PSF Stronger performance enhancing effect of the PSF Nominal error rate 1 0E 2 for diagnosis 1 0E 3 for actions Lower human error probability 1E 5 3 PSF Figure 3 Ideal mean HEP as a function of PSF influence 3 Table 3 Proposed PSF for risk assessment 1 1 1 0 2 i 1 0 3 1 1 0 4 1 1 0 5 1 1 0 6 1 1 0 7 1 1 0 8 1 1 0
33. YW PSF level pa a xr S 3H i far RA No 1 2 3 4 RA RA 100kg 5 15kg
34. RTARTA 12cm aaa Vy Y 15 0 1 2 3 PSF T 4 5 6 PSF 2 7 8 9 10 PSF 3 9 Figure 9 PSF evaluation sheet for pullman loaf slicer RA RA RA 2 RA
35. R S P F H R S x P x F x H 7 Figure 7 Numerical scoring and its elements JIS B9 705 1 2000 B 1 6 2 2 Figure 6 Risk graph for risk estimation 2 2 ARMED 1 2 3 1 10 H 5 3 2 2 8 1 4 5
36. BORD MBA LY GLE SHO BO CHS 4 a b Performance Shaping Factor PSEDD PSF ec PSF 3 PSF d 2 2 1
37. DIN W3 W2 W1 PSF2 PSF1 PSF3 4H 5 1 2 Figure 5 Risk graph for risk estimation 1 2 4 4 ROME PMO Y he HOW 7 S P G 6 F R Im ace o lt ze Im 1 2 g sc sw zeF
38. eeeseseseeseseseeeeeeeeeeeseseeeeeeseeseseseeeeseseseeseseseeseseseesesesereeseseseesesesseseseseeseseseeeesreseeseseseesereseseesereeeesereseeeere 2 7 Figure 2 Pullman loaf slicer example 8 9 2 1 HEP 1 HEP 102 104 HEP
39. nd 2008 130 18 YW PSF VED DO it TE n ip BN 5 6 7 F RIAD EHORNAV AD H i H i PSF level N f R kh
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