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(shū)作者）列出了50個(gè)問(wèn)題，可在任何人為失誤調(diào)查過(guò)程中用作指導(dǎo)。這些問(wèn)題的目的是更好地了解與所調(diào)查問(wèn)題相關(guān)的人為因素。這不是一份簡(jiǎn)單的清單，應(yīng)該與常規(guī)的根本原因分析工具（如因果圖和故障樹(shù)分析）一起使用。這些問(wèn)題的答案將為以下調(diào)查要素提供有價(jià)值的信息：

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Identifying contributing root causes

找出根本原因

●

Identifying situational factors

確定情景因素

●

Identifying latent factors

識(shí)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(lèi)

1.

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

此人是否無(wú)意識(shí)地錯(cuò)誤執(zhí)行了任務(wù)（委托錯(cuò)誤）？

2.

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

此人是否無(wú)意識(shí)地漏掉了任務(wù)或任何步驟（遺漏錯(cuò)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(shè)計(jì)的記錄是否便于識(shí)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(shí)別缺陷、信息、信號(hào)等（識(shí)別錯(cuò)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(dǎo)書(shū)規(guī)定的方式執(zhí)行任務(wù)？

Procedure Quality and Content

程序質(zhì)量和內(nèi)容

6.

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

是否有執(zhí)行這項(xiàng)任務(wù)的正式（書(shū)面）指導(dǎo)書(shū)？

7.

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

執(zhí)行任務(wù)的鄰近區(qū)域是否有程序或工作指導(dǎo)書(shū)？

8.

Did the procedures or work instructions change recently?

程序或工作指導(dǎo)書(shū)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(wù)時(shí)是否閱讀了程序或工作指導(dǎo)書(shū)？

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(dǎo)書(shū)是否使用了具體細(xì)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(xiàng)任務(wù)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(xiàng)任務(wù)的方式是否一致？

13.

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

錯(cuò)誤是否與數(shù)字或字母信息（規(guī)格、批號(hào)）有關(guān)？

Training

培訓(xùn)

14.

Was the person formally trained on the task or procedure?

該人員是否接受過(guò)有關(guān)任務(wù)或程序的正式培訓(xùn)？

15.

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

培訓(xùn)方法是否適合這項(xiàng)任務(wù)？描述所使用的方法。

16.

Does the training cover this specific task?

培訓(xùn)是否涵蓋這項(xiàng)具體任務(wù)？

17.

How long was the training for this specific task?

這項(xiàng)具體任務(wù)的培訓(xùn)時(shí)間有多長(zhǎng)？

18.

How recently did the person receive the training?

此人最近接受過(guò)什么培訓(xùn)？

19.

Who trained this person?

誰(shuí)培訓(xùn)的這個(gè)人？

20.

Who trained the other people who did the task correctly?

是誰(shuí)培訓(xùn)了其他正確完成任務(wù)的人？

21.

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

培訓(xùn)結(jié)束后，如何評(píng)估有關(guān)人員的能力？

22.

Was the training effectiveness evaluated? Describe the method used.

是否對(duì)培訓(xùn)效果進(jìn)行了評(píng)估？說(shuō)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(wù)是否會(huì)干擾這項(xiàng)任務(wù)的執(zhí)行？

24.

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

最近是否對(duì)不符合的區(qū)域進(jìn)行過(guò)干預(yù)？

25.

Were all the area personnel present when the error occurred?

錯(cuò)誤發(fā)生時(shí)，所有區(qū)域人員是否都在場(chǎng)？

26.

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

錯(cuò)誤發(fā)生時(shí)，主管或組長(zhǎng)在場(chǎng)嗎？

27.

Did the error occur during overtime?

錯(cuò)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(cuò)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(cuò)誤是在停機(jī)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(shí)間緊迫的情況嗎？

31.

Was it a situation of competing priorities?

這是優(yōu)先事項(xiàng)相互競(jìng)爭(zhēng)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(xiàng)任務(wù)時(shí)，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?yàn)榉浅Ｊ煜と蝿?wù)而在自動(dòng)駕駛模式下工作？

34.

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

此人是否在同時(shí)執(zhí)行其他任務(wù)（多任務(wù)處理）？

35.

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

任務(wù)是否需要處理太多信息或同時(shí)關(guān)注太多事情？

36.

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

這項(xiàng)任務(wù)是否要求當(dāng)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(guò)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(wú)章，需要人們四處移動(dòng)才能完成任務(wù)？

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(guān)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(lái)專(zhuān)門(mén)避免這種故障？

42.

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

是否對(duì)控制措施進(jìn)行過(guò)質(zhì)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(xiàng)任務(wù)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(nèi)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(xiàng)任務(wù)是否包括第二人驗(yàn)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(xiàng)任務(wù)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(xiàng)任務(wù)是什么時(shí)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(zhǎng)時(shí)間做一次這項(xiàng)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(wù)？

49.

Has the person performed the task correctly earlier?

他之前是否正確地完成了任務(wù)？

50.

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

去年發(fā)生這種（或類(lèi)似）錯(cuò)誤的頻率是多少？