随着高科技的发展和人机系统的日益复杂化，硬件及设备本身的可靠性日益加 强，但人的失误对于系统失效的影响却变得更加显著。研究表明，一些严重的恶性 事故的发生都与人的失误有直接关系。在核电厂、航空、化工等复杂系统中，由人 引发的系统失效约占到70%-90%。美国著名质量管理专家Juran与Gryna通过大量 调查研究发现，对于中等复杂程度以上产品而言，40%的故障是由于设计原因造成， 30％的故障归咎于现场管理失误，30％的故障归咎于加工中存在的人为过失。 本论文以斯弗苏州公司生产线人因失误问题为研究主题，首先通过整理和分析 历史人因失误数据，分析生产线人因失误的类型、后果、特征和原因，然后通过开 展问卷和访谈调查，将收集到的人因失误一手数据按照任务、组织、个人和环境四 个方面进行原因分析，然后利用FMEA失效模式与影响分析方法量化分析人因失误 风险模式的危急程度和控制水平，最后通过综合分析人因失误的产生原因并结合人 因失误的风险等级，提出针对性的预防对策。 论文结论表明，人因失误事故占斯弗苏州公司生产线事故总数的48.4%，个人 因素是人因失误的主要原因，尤其心理因素不容忽视。但人因失误是多因素综合作 用的结果，组织因素和环境因素是产生人因失误的隐形原因和深层次原因，比如交 接班管理、培训授权管理、生产班次和轮休制度等，在环境因素方面，人因失误表 现出显著的“时间”特征。基于人因失误原因分析结论和不同的风险等级，提出了 12项人因失误预防对策。 关键词：人因失误，调查研究，预防策略，FMEA分析 MBA学位论文 作者：梁志勇 斯弗苏州公司生产线人因失误调查及预防策略研究 II HUMAN ERROR INVESTIGATION AND PREVENTION STRATEGY OF PRODUCTION LINE IN SF SUZHOU CORPORATION Abstract Along with the development of high-tech and the complexity of the man-machine system, the reliability of hardware and device itself increasingly strengthened, but the human error influence becomes more important for the system. Research has shown that some serious accident is directly related to the human error. About 90% to 70% system failure is caused by human error in the nuclear power plant, aviation, chemical and other complex systems. Famous American quality management expert Juran and Gryna had a lot of investigation and study, found that for moderate complexities of above products, 40% of the failures are caused by design reason, 30% of the failure is due to the site management error, and 30% of the failure is due to human error that exist in the process. This paper takes human error of SF Suzhou corporation production line as the research subject, first of all, by collating and analyzing historical human error data, analyzing the human error in terms of types, characteristics, consequences and causes, and then collect the primary data through questionnaire and interview survey, and study the human error generation cause. Then identify and evaluate the criticality and control level of potential human erro risk model, finally propose human error prevention strategies based on the summary of human error cause and human risk classification. The conclusions show that 48.4% of the total number of aviation production accidents were caused by human error, and personal factors is a major cause of human error and psychological factors cannot be ignored especially. However human error is a result of the combined action of multiple factors, organizational factors and environmental factors are the recessive and deep-seated reasons, such as shift handing-off management, training and authorization management, production shifts and days off, etc., in terms of environmental factors, the analysis result shows the significant characteristics of "time". 12 prevention strategy was proposed based on cause analysis and FMEA analysis.