认知可靠性和失误分析方法在船舶引航事故分析中的应用  

Application of Cognitive Reliability and Error Analysis Method in Analysis of Ship Piloting Accidents

作　　者：高泽华 李亮 GAO Zehua;LI Liang(Shanghai Maritime Pilots’Association,Shanghai 201306,China)

机构地区：[1]上海港引航站,上海201306

出　　处：《上海船舶运输科学研究所学报》2024年第5期38-44,共7页Journal of Shanghai Ship and Shipping Research Institute

摘　　要：为准确判断引发船舶引航事故的人因失误,以便采取有效措施防止类似失误出现,采用认知可靠性和失误分析方法(Cognitive Reliability and Error Analysis Method,CREAM)对引航事故进行分析。基于CREAM方法中的追溯性分析方法建立引航事故追溯模型,构建前因分类表、后果-前因链表和失误模式-前因表等3种人因失误因子关系表,实现对引航事故原因的追溯。以某典型船舶搁浅事故为例,采用该方法追溯导致事故发生的人为因素,并将所得结果与已有事故调查报告中的事故分析结果相对比,验证该方法的有效性。在此基础上,提出提升船舶引航安全性的建议,包括加强对引航员的教育与培训、提升引航设施的可靠性和严格落实规章制度等,为后续船舶引航作业的安全开展提供参考。In order to accurately determine the human error factors that causes pilotage accidents and take effective measures to prevent similar accidents from occurring,the Cognitive Reliability and Error Analysis Method(CREAM)is used to analyze pilotage accidents.Based on the retrospective analysis function in the CREAM,a pilotage accident retrospective model is established,and three types of human error factor relationship tables(the Genotypes Tables,General and Specific Antecedent Tables,Error Mode Antecedent Table)are constructed.Based on these tables,the causes of pilotage accidents are traced.With a typical grounding accident as the example,the method is used to trace the human factors that lead to the grounding,and the results is compared with the accident analysis results in the existing accident investigation report to verify the effectiveness of the method.Suggestions for improving the safety of ship pilotage are put forward,including strengthening the education and training of pilots,improving the reliability of pilotage facilities,and strictly implementing regulations,etc.

关 键 词：船舶安全 引航 人的可靠性 认知可靠性和失误分析方法(CREAM) 

分 类 号：U675.9[交通运输工程—船舶及航道工程] U698.6[交通运输工程—船舶与海洋工程]