I've listed 50 questions that can be used as guidance during any investigation of human errors. The purpose of these questions is to obtain a better understanding of the human factors surrounding the issue under investigation. This is not a mere checklist, and it should be used along regular root cause analysis tools such as cause-and-effect diagrams and fault tree analysis. Answers to the questions will provide valuable information regarding the following elements of the investigation:

“我”（書作者）列出了50個問題，可在任何人為失誤調查過程中用作指導。這些問題的目的是更好地了解與所調查問題相關的人為因素。這不是一份簡單的清單，應該與常規(guī)的根本原因分析工具（如因果圖和故障樹分析）一起使用。這些問題的答案將為以下調查要素提供有價值的信息：

●

Identifying contributing root causes

找出根本原因

●

Identifying situational factors

確定情景因素

●

Identifying latent factors

識別潛在因素

●

Identifying absent or insufficient control barriers

確定缺少和不充分控制屏障

Classification of Human Errors/Violations

人為失效/違規(guī)的分類

1.

Did the person unconsciously perform the task erroneously (commission error)?

此人是否無意識地錯誤執(zhí)行了任務（委托錯誤）？

2.

Did the person unconsciously miss the task or any step (omission error)?

此人是否無意識地漏掉了任務或任何步驟（遺漏錯誤）？

3.

If this was a documentation omission, is the record designed to identify omissions easily?

如果是文件有遺漏，設計的記錄是否便于識別遺漏？

4.

Did the person fail to recognize a defect, message, signal, and so on (recognition error)?

此人是否未能識別缺陷、信息、信號等（識別錯誤）？

5.

Did the person intentionally perform the task differently than specified in the procedures or work instructions?

此人是否故意以不同于程序或工作指導書規(guī)定的方式執(zhí)行任務？

Procedure Quality and Content

程序質量和內容

6.

Are there formal (written) instructions to perform this task?

是否有執(zhí)行這項任務的正式（書面）指導書？

7.

Were procedures or work instructions available in the immediate area where the task was performed?

執(zhí)行任務的鄰近區(qū)域是否有程序或工作指導書？

8.

Did the procedures or work instructions change recently?

程序或工作指導書最近是否有變更？

9.

Did the person read the procedures or work instructions while executing the task?

此人在執(zhí)行任務時是否閱讀了程序或工作指導書？

10.

Did the procedures or work instructions use specific details rather than a qualitative description (slowly, soon, few, well, and so on)?

程序或工作指導書是否使用了具體細節(jié)，而不是定性描述（慢、快、少、好等）？

11.

Does the person need to process or interpret information to execute this task?

執(zhí)行這項任務需要處理或解釋信息嗎？

12.

Is there consistency in how other people are performing this task?

其他人執(zhí)行這項任務的方式是否一致？

13.

Is the error related to numbers or alphanumeric information (specifications, batch numbers)?

錯誤是否與數(shù)字或字母信息（規(guī)格、批號）有關？

Training

培訓

14.

Was the person formally trained on the task or procedure?

該人員是否接受過有關任務或程序的正式培訓？

15.

Is the training method appropriate for this task? Describe the method used.

培訓方法是否適合這項任務？描述所使用的方法。

16.

Does the training cover this specific task?

培訓是否涵蓋這項具體任務？

17.

How long was the training for this specific task?

這項具體任務的培訓時間有多長？

18.

How recently did the person receive the training?

此人最近接受過什么培訓？

19.

Who trained this person?

誰培訓的這個人？

20.

Who trained the other people who did the task correctly?

是誰培訓了其他正確完成任務的人？

21.

How was the competence of the person assessed after completion of the training?

培訓結束后，如何評估有關人員的能力？

22.

Was the training effectiveness evaluated? Describe the method used.

是否對培訓效果進行了評估？說明使用的方法。

Situational Factors

情景因素

23.

Are other tasks interrupting the performance of this task?

其他任務是否會干擾這項任務的執(zhí)行？

24.

Have there been any recent interventions in the area affected by the nonconformity?

最近是否對不符合的區(qū)域進行過干預？

25.

Were all the area personnel present when the error occurred?

錯誤發(fā)生時，所有區(qū)域人員是否都在場？

26.

Was the supervisor or group leader present when the error occurred?

錯誤發(fā)生時，主管或組長在場嗎？

27.

Did the error occur during overtime?

錯誤發(fā)生在加班期間嗎？

28.

Did the error occur prior to or after a break or shift change?

錯誤發(fā)生在休息或換班之前還是之后？

29.

Did the error occur prior to or after a shutdown or vacation period?

錯誤是在停機或休假之前還是之后發(fā)生的？

30.

Was it a situation with a very tight deadline?

是時間緊迫的情況嗎？

31.

Was it a situation of competing priorities?

這是優(yōu)先事項相互競爭的情況嗎？

Latent Factors

潛在因素

32.

Did the person work from memory while executing this task?

在執(zhí)行這項任務時，他是憑記憶工作的嗎？

33.

Was the person working in autopilot mode because he/she was very familiar with the task?

此人是否因為非常熟悉任務而在自動駕駛模式下工作？

34.

Was the person performing any other task concurrently (multitasking)?

此人是否在同時執(zhí)行其他任務（多任務處理）？

35.

Does the task require processing too much information or focusing on too many things at the same time?

任務是否需要處理太多信息或同時關注太多事情？

36.

Does the task require the person to follow a specific sequence of steps?

這項任務是否要求當事人遵循特定的步驟順序？

37.

Was the area's layout or workspace overcrowded?

該區(qū)域的布局或工作空間是否過于擁擠？

38.

Was the area disorganized, requiring people to have to move around to perform tasks?

該區(qū)域是否雜亂無章，需要人們四處移動才能完成任務？

39.

Were the working conditions comfortable (noise, temperature, humidity, illumination [well-lit with bright light], etc.)?

工作條件是否舒適（噪音、溫度、濕度、照明[光線充足、明亮]等）？

40.

Is the system or process intuitive enough to be understood easily?

系統(tǒng)或流程是否足夠直觀，易于理解？

Control Related

相關控制

41.

Is there any control (barrier) in place to specifically avoid this failure?

是否有任何控制措施（屏障）來專門避免這種故障？

42.

Has the control been challenged to determine if it is working?

是否對控制措施進行過質疑，以確定其是否有效？

43.

Are there any job aids or checklists to perform this task?

是否有執(zhí)行這項任務的工作輔助工具或檢查表？

44.

Are their format/contents appropriate for clear interpretation?

它們的格式/內容是否適合清晰解讀？

45.

Did the employee use the job aid(s)?

員工是否使用了工作輔助工具？

46.

Does this task include a second person verification or checking?

這項任務是否包括第二人驗證或檢查？

Skill Fading

技能退化

47.

Is this the first time the person performed this task?

他是第一次執(zhí)行這項任務嗎？

a. If it’s not the first time, when was the last time he/she performed this task?

a. 如果不是第一次，他/她上一次執(zhí)行這項任務是什么時候？

b. If it’s not the first time, how often does the person perform this task?

b. 如果不是第一次，此人多長時間做一次這項工作？

48.

How many other people do the same task correctly under the same conditions?

在相同條件下，還有多少人能夠正確完成同樣的任務？

49.

Has the person performed the task correctly earlier?

他之前是否正確地完成了任務？

50.

How often did this (or similar) error occur during the last year?

去年發(fā)生這種（或類似）錯誤的頻率是多少？