人为失误与预防(上海)课件

Accidentswillbeoftenhappenedintheair,onthehighwaysandrailways,butitwillbehappenedatseaaswell.

事故经常在空中、公路与铁路上发生，但也经常在大海上发生。Accidentswillbeof1Collision(碰撞)Collision(碰撞)2Grounding(搁浅)Grounding(搁浅)3Flooding(进水)Flooding(进水)4OnFire(火灾)OnFire(火灾)5Pollution(污染)Pollution(污染)6Evenifwehavehadgoodskillormadeproperprocedure即使我们具有良好的技能或制定了正规的程序，缺少正确的态度，还是会导致事故的发生。Evenifwehavehadgoodskill7C=A×（K+S）C–Capacity能力A–Attitude态度K–Knowledge知识S–Skill技能主要是为了：理念的改变；态度的改变；行为的改变。发现不足，确保成功。C=A×（K+S）8HumanError&Accidents

人为失误与预防HumanError&Accidents

9

HUMANERROR&ACCIDENTS

人为失误与事故

MarineAccidents（海上事故）

Maritimeaccidentsordisastersareveryseldomtheresultofasingleevent.海上事故或灾难很管理少是由一个事件造成的

Theyarealmostalwaystheresultofseriesofnon-seriousincident;theculminationofanERRORCHAIN.

它们几乎总是由一系列不严重的事件导致的;它们是失误链发展的最终结果

HUMANERROR&ACCIDENTS

人为失误与10Definition(定义)

Errorcouldbeneglectandmistakes失误为过失与错误。Itmeansthatyoushoulddo,butyouhavenotdone;Whichyoushouldnotdo,butyouhavedone.

你应该做的而未做，不该做的已做了。Definition(定义)

Errorcouldb11ASeriesofeventsorthechainofevents,whichleadstoanaccident导致事故的一系列事件或事件链

ErrorChainLinks失误链的连接Occursequentially顺序地发生

Mayormaynotberelated;mayormaynotbeapparent可能有或没有联系;可能明显或不明显ASeriesofeventsorthec12海因里希事故因果链Heinrich’scauseandeffectchainofaccidents海因里希事故因果链13Identification(识别)

Beingawareofthesituationaroundyourself(I.e.SituationalAwareness)helpsyourecognizetheformationofanerrorchain.Basedonthisawareness,taketheappropriateactiontoBREAKthechainofevents.

了解你自己周围局面的情况（即情景意识）帮助你认识一个失误链的形成，在此认识基础上，采取相应的措施来终止事件链。

Identification(识别)

B14Signs(迹象)

Thesignsindicatingtheformationofanerrorchainarethesameasthesignsindicatingthelossofsituationawareness.

表明失误链形成的迹象与丧失情景意识的迹象是一样的。

ThuswiththelossofSituationalAwarenesscomestheformationofanErrorChain.

因此，丧失情景意识致使失误链得以形成。

Signs(迹象)

Thesignsin15SignsforIndicatingtheFormationofanErrorChain(表明失误链形成的迹象)

A.Ambiguity不确定性B.Distraction注意力分散C.Feelingofinadequacyorconfusion感知不全面或混乱D.Communicationbreakingdown通信中断E.ImproperCONNorlookout指挥或监测不当F.Departurefromconditionplan偏离设定工况G.Violationofestablishedrulesorprocedures违反已建立的规则或程序H.Complacency自满SignsforIndicatingtheForma16A.Ambiguity不确定性

When2ormoreindependentsourcesofinformationappearstodisagree当二种或二种以上单独的信息源产生矛盾时:People人员Equipment设备Rules,regulations,procedures,systems法规、规则、程序与系统Oranycombinationofthese或其他合成的来源A.Ambiguity不确定性

When2ormo17Ambiguityitselfmaynotbedangerous,butitmeansthatthereisadifferenceandthecauseofthisdifferenceneedstobeverified.Ambiguitymaybearesultofinexperienceorlackoftraining.不确定性本身也许不危险，但它意味着有差异，但差异原因需要证实。不确定性也可能是经验不足或缺乏训练的结果Ambiguityitselfmaynotbe18B.Distraction注意力分散

Distractioncanbecausedby:

注意力分散可由下列因素造成：BreakdowninLeadershipandManagementskills领导与管理的失误；

excessiveworkload/stress/fatigue超负荷工作/压力/疲劳；emergencysituations紧急情况；

inattention注意力不集中；

inexperience经验不足。B.Distraction注意力分散

Distra19Focusofattentionononeinputorcomponentofsituationalawarenesstotheexclusionofothers，suchasatellcall,whichcanoccupythefullattentionofapersontotheexclusionofothermoreurgentneeds.Itisanotherformofthedistraction.

注意力集中在一个问题或情景意识的某一方面，例如电话呼叫，它可吸引一个人的全部注意力，从而忽视了处理其它更紧迫的事件从而忽视了其它情况。这是注意力分散的另一种形式。Focusofattentiononone20C.FeelingofInadequacyorConfusion

感知不全面或混乱

Afellingoflossofcontrolofthesituationsuchthatthepersonconcerneddoesnotknowwhatisexpectedtohappennext.Frequentlytheresultoflackofexperience.

对失去局面控制感的人员是不知道随后将会发生什么的。这往往是由于经验缺乏造成的。

Asenseofuncertaintyorconfusionaboutasituationcausedbylackofprofessionalintuitionandcognitivedissonance

对局面难以确定和发生感觉混乱通常是缺乏职业的直觉和认知不清而发生的。C.FeelingofInadequacyorCo21D.CommunicationBreakingDown

通信中断

Internalcommunicationsmaybeconfusedbyphysicalcausessuchasnoise,etc.orbecausedbylackofacommonlanguageordifferingproceduralmethods.Externalcommunicationsbreakdownmayalsobecausedbyanon-commonlanguageorplainmisunderstanding.

船内通信可能被物理因素所干扰，例如噪声等。也可能因缺乏共同语言或不同的处理方法而中断。外部通信的中断可能是没有共同语言或误解造成的。

D.CommunicationBreakingDown22Improperorpoorcommunicationswhichresultin：不正确或不良的通信将导致:Directionsnotbeingexecutedproperly指令不能被正确执行；Theneedforrepetitionofdirections.要求重复指示；MissedMessages丢失信息；Incompleteacceptanceorunderstandingoftheplan

不能完整的接受和理解计划。Improperorpoorcommunication23E.ImproperCONNorlookout

指挥或监测不当

Improperconningandpoorlookoutmaybearesultoflackofsituationalawarenessaswellasanindicationofitsbreakdown.

指挥或监测不当可能是由情景意识不够，也意味着错误的表现。

E.ImproperCONNorlookout

24Forexamples例如:Notexercisingappropriatecontrolanddirection.未能加以适当的控制与指挥

Excessivespeed超速；

Improperoperationoftheengine机器不正确的运行.

Notstationingappropriatelookouts未能安排好监测人员

Insufficientqualifiedpersonnelforthetaskat

hand身边能胜任工作的人员不足。Forexamples例如:25F.DeparturefromConditionPlan

偏离设定工况

DeparturefromthePlanedconditionmaybearesultimproperconningorimpropermonitoringoftheoperationoftheengine.

偏离设定工况可能是由于在机器运行中的指挥或监控不当而造成的。F.DeparturefromConditionPl26Notbuildinganddisseminatingtheconditionoftheengine未制定或落实好设定工况；Unplanned/undresseddeparturesfromaconditionoftheengine未能计划和造成对设定工况的背离；Failuretomeetthegoalsandtargetsofanestablishedplanwithoutfollow-up未能采取进一步的措施达到已制定计划的目的与要求。Notbuildinganddisseminatin27G.ViolationofEstablishedRulesorProcedures违反已建立的规则或程序

Departurefromclearlydefinedrulesandstandardoperatingprocedureswithoutjustification，suchas:Rulesoftheportauti-pollution,EngineProcedures,Engineeringoperationandcompanypolicy

没有正当理由而背离明确规定的规则和标准操作程序。例如：港口防污规则、机炉舱规则、轮机操作程序和公司政策等。G.ViolationofEstablishedRu28

H.Complacency自满

Overconfidence过于自信；Over-familiaritywiththerouteorthetaskathand对手中工作与任务过于熟悉；Ignoringorbelittlingpotentialproblems不考虑和轻视潜在问题；Beinglulledintoafalsesenseofsecurity自我认为很安全。

H.Complacency自满

Overconfiden29Whatcancauseerrors?

哪些因素会产生过失?

Therearemanycombinationsandwaysinwhicherrorscanoccur,bothtechnicalerrorsofshipandhumanerror.

过失的产生因素有多种，包括船舶的技术性故障和人为失误。

Whatcancauseerrors?

哪些因素会产生30TechnicalErrorsofengine

（机器的技术性故障）

涉及到机器运行的主要技术参数超限报警，如未被发觉，将导致机器处于失控的状态，从而进一步引起更大的故障。Referredtothemachinelimitexceedingalarmofmaintechnicalparametersinrunning,ifnotnoted,itwillleadtowildconditionandcauseseverertroubles.TechnicalErrorsofengine

（机器31ErrorsfromEquipmentandInformation因设备与资料产生的失误

Totalorintermittentfailure完全故障或间歇性故障Malfunctionofsafetysystemsandalarms安全系统和报警故障Misleadinginformationfromuncalibratedinstruments从未标准化的设备获得的错误信息Improperofsystemduetoanunturnedequipment由于某些设备未开启动而造成系统不正常Outofdateinformationonpapersandinstraction图纸和说明书上的错误信息ErrorsfromEquipmentandInfo32HumanBeings（人）

Humanbeingsarenotmachines人非机器Humansaregoodatassessingthesituationapplyingknowledgeandsolvingproblems.

Humansarebadatsustaininglongrepetitivetasks,concentratinghardforlongperiodswithoutabreak,aresubjecttotirednessandfatigueandthedullingeffectsofboredom.

人擅长于应用知识来分析局面，解决问题。人不擅长于长时间进行重复工作和长期不间歇地保持精神高度集中，易于因厌烦、疲劳和枯燥而产生迟钝。

HumanBeings（人）

Humanbeingsa33Forthehumanerrors,itispossiblethatanoperatormaymakeamistake.对于人为过失而言，它可能是指操作者也许会犯错误。ThismightbetheMMwhooperatesthewrongcourse,ortheOEWwhomakesanerror,orChiefengineerdecidewrongly.它可能是机工操作失误、值班轮机员管理不当或轮机长决策错误。Forthehumanerrors,itispo34KindsofHumanError

人为过失的种类UnintentionalActionIntentionalActionUnsafeAct&DecisionSlipsLapseMistakesViolationSkill-BasedAttentionalFailure&MemoryFailureRule-Based&Knowledge-basedMistakeKnowledge-basedRoutise&ExceptionalAdapationsBasicErrorTypesKindsofHumanError

人为过失的种类Un35KindsofHumanError

人为过失的种类KindsofHumanError

人为过失的种类36KindsofHumanError

人为过失的种类

A.Slipsandlapses疏忽和差错

B.Rule-basedmistakes基于法规的错误

C.

Knowledge-basedmistakes基于知识的错误D.CulturalConditioning文化制约

E.Violationofsafepractices违反安全惯例

KindsofHumanError

人为过失的种类

37Slips&Lapses

疏忽和失误

Distractionandpreoccupation

注意力分散和偏见

Changestonormalexpectedcircumstances

正常可预见环境的变化

Stressandfatigue

压力和疲劳

Slips&Lapses

疏忽和失误

Distr38KindsofHumanError

人类错误的性质

A.Knowledge-BasedMistakes基于知识的错误;B.Rule-basedMistakes基于法规的错误；C.Skill-BasedMistakes基于技能的错误；D.CulturalConditioning文化的制约；E.ViolationofSafePractice违反安全惯例。KindsofHumanError

人类错误的性质A39A.Knowledge-BasedMistakes

基于知识的错误

Realweaknessduetoignorance

由于无知而犯错Overconfidenceduetoignorance

由于无知而自负Amistakenunderstandingoftheprinciplesinvolved

有关原则的理解错误A.Knowledge-BasedMistakes

40B.Rule-basedMistakes

基于法规的错误Makingaquickdecisionwithoutconsiderationoftherules；

没有考虑法规而草率决定；Notnoticingwhenaruledoesnotwork；

没有注意到法规不适用；Misapplyingtoshortcutrules；

错误应用“简化的”法规；

Makingerrorsfromambiguousinformation；由于信息不明确而犯错。B.Rule-basedMistakes

基于法41C.Skill-BasedMistakes

基于技能的错误Lackofthetraining

缺乏训练Notexchangeoftheexperience

不交流经验LessPracticalOperation

实际操作过少C.Skill-BasedMistakes

基于42D.CulturalConditioning

文化制约

Culturalconditioningcancauseembarrassmentinthecommandstructurefoundonboardships.文化制约在船上的指挥结构中会造成问题。

Someculturesreinforceanacceptanceofauthoritysothatitisverydifficulttoquestionseniorofficerswithoutfeelinguncomfortable.有些文化可加强对权威的认可，以致质询高级船员时因感到不自在而变得十分困难

Otherculturalinfluencesincludepossiblemisunderstandingsofintentionsandawillingnesstocomplywithoutquestion.其他文化影响包括可能对意图的误解和毫无疑问地服从。D.CulturalConditioning

43E.ViolationofSafePractice

违反安全惯例

-Complacency自满

-Apathyleadingtolazinessratherthancompliance冷漠导致懒惰而不是遵守；

-Experimentation凭经验；

-Adesiretopushlimitsratherthancomply被迫执行而不是出自意愿的遵守；

-Motivationalandbehavioralproblemsindividuallyandintheteam个体或团队的动机与行为问题E.ViolationofSafePractice

44

-Sometimescomplacencymeansoverconfidence有时自满意味着过于自信-Itincludestheneglectadvicefromothers

它包括忽视别人的建议，

-Neglecttoconsulttobooksorpublications

忽视查阅书或出版物

-NeglecttoconsulttoRulesandRegulations

忽视查阅法规

-Departurefromconditionplan

偏离设定工况

-Sometimescomplacencymea45BreakingtheErrorChains

破断失误链(1)

-Recognizingthepossibilityoftheerrorchainandrelevantlinkages认识失误链与相关的环节存在的可能性-Identifyingofexistingerrorchainandrelevantlinkages辨清现有失误链及其相关的环节-Takingactiontobreaktheerrorchainandmakingpropermeasuretopreventtheoccurrenceoferrorchainagain.采取行动破断失误链并制定防止失误链的再次产生。-Itisdifficulttoavoidtheoccurrenceoftheerrorchain,butitmusttousingtheAbortPointtobreaktheerrorchain.虽然难以避免失误链的产生，但必须采用中断点来破断失误链。

BreakingtheErrorChains

破断失误46BreakingtheErrorChains

破断失误链(2)

Examinationofwhetheranerrorchaininactionallthetime始终注意事故链的是否存在Takingactiontoresolvetheevent/linkpriortoanaccident在事故发生前采取措施解决问题Breakinganerrorchainwillcauseanaccident

nottohappen破断失误链可避免事故的发生

BreakingtheErrorChains

破断失误47HowtoAvoidError

如何预防过失的产生

Planaheadandknowwhattoexpectandtodo提前做好计划，知道将要发生什么和怎么做Developsaferoutinesandhabitstoensuremostsafepracticesarecoveredundernormaloperations,whilstleavingtimeandenergytosolvedifficultproblems

Applyselfcheckinghabitstoallactivities培养安全的做法与习惯，保证在正常操作中能使用安全的惯例，以留出时间和精力来解决难题。Checkandmonitorothersandexpectotherstocheckandmonitoryou检查和监督其他人，同时也乐于接受他人的检查和监督。HowtoAvoidError

如何预防过失的产生

48

国际海事组织（IMO）关于上世纪八、九十年代船舶事故高发阶段的统计表，世界四大柴油机制造商上世纪末的统计资料都说明了事故的原因80％以上在于人为因素。ThestatisticsofIMOinhighincidencestageofmarineaccidentsin1980-2000,andthestatisticdatafrom4maindieselenginemanufacturesintheendoflastcenturyallshowthatthehumanbeingfactorisabove80%inaccidents.国际海事组织（IMO）关于上世纪八、49表11987~1991年世界全损船舶按船型统计

Table1Thetotallossshipsstatisticbyshipformin1987-1991198719881989ShipformshipsGrosstonnage％ships总吨％shipsGrosstonnage％Oilship91316361113144371191331346429Bulkandcombinationcarrier24639834548133654171630633728other106407503351264978316412745827643Sumtotal13911789731001477758561001561078077100！表11987~1991年世界全损船舶按船型统计

Tab50表11987~1991年世界全损船舶按船型统计

Table1Thetotallossshipsstatisticbyshipformin1987-1991！19901991ShipformshipsGrosstonnage％shipsGrosstonnage％Oilship14224884182050166329Bulkandcombinationcarrier19704615582772007742other1062916262413548672429Sumtotal13912211251001821708464100表11987~1991年世界全损船舶按船型统计

Ta51船舶机械故障分析

TheanalysisofmachinefailureonboardInvarioustroubles，themainenginefailureismost，accountingforabout38%。表2各种机械发生故障的比例Table2ThefailurerateofvariousmachineriesMachinevarietyMEDEGERADMVALEElectromotorothermarkhuman×hours（％)36.619.317.96.3Thesumfailuretimes7521Failuretimes（％)3815.710.99.7船舶机械故障分析

Theanalysisofmachi52船舶机械故障分析

TheanalysisofmachinefailureonboardInmainenginefailures，theratesofmaterialanddefilingproblemarebig，respectivelyis24.3%and24.7%。表3按主机故障原因分类的发生故障的比例（%）Thefailureratebydifferentcausesofmainengine(%)

DesignmaterialinstallationoperationSpontaneousabrasioncauterydefilevibrationmanagement1.910.510.424.710.01.3船舶机械故障分析

Theanalysisofmachi53Accidentswillbeoftenhappenedintheair,onthehighwaysandrailways,butitwillbehappenedatseaaswell.

事故经常在空中、公路与铁路上发生，但也经常在大海上发生。Accidentswillbeof54Collision(碰撞)Collision(碰撞)55Grounding(搁浅)Grounding(搁浅)56Flooding(进水)Flooding(进水)57OnFire(火灾)OnFire(火灾)58Pollution(污染)Pollution(污染)59Evenifwehavehadgoodskillormadeproperprocedure即使我们具有良好的技能或制定了正规的程序，缺少正确的态度，还是会导致事故的发生。Evenifwehavehadgoodskill60C=A×（K+S）C–Capacity能力A–Attitude态度K–Knowledge知识S–Skill技能主要是为了：理念的改变；态度的改变；行为的改变。发现不足，确保成功。C=A×（K+S）61HumanError&Accidents

人为失误与预防HumanError&Accidents

62

HUMANERROR&ACCIDENTS

人为失误与事故

MarineAccidents（海上事故）

Maritimeaccidentsordisastersareveryseldomtheresultofasingleevent.海上事故或灾难很管理少是由一个事件造成的

Theyarealmostalwaystheresultofseriesofnon-seriousincident;theculminationofanERRORCHAIN.

它们几乎总是由一系列不严重的事件导致的;它们是失误链发展的最终结果

HUMANERROR&ACCIDENTS

人为失误与63Definition(定义)

Errorcouldbeneglectandmistakes失误为过失与错误。Itmeansthatyoushoulddo,butyouhavenotdone;Whichyoushouldnotdo,butyouhavedone.

你应该做的而未做，不该做的已做了。Definition(定义)

Errorcouldb64ASeriesofeventsorthechainofevents,whichleadstoanaccident导致事故的一系列事件或事件链

ErrorChainLinks失误链的连接Occursequentially顺序地发生

Mayormaynotberelated;mayormaynotbeapparent可能有或没有联系;可能明显或不明显ASeriesofeventsorthec65海因里希事故因果链Heinrich’scauseandeffectchainofaccidents海因里希事故因果链66Identification(识别)

Beingawareofthesituationaroundyourself(I.e.SituationalAwareness)helpsyourecognizetheformationofanerrorchain.Basedonthisawareness,taketheappropriateactiontoBREAKthechainofevents.

了解你自己周围局面的情况（即情景意识）帮助你认识一个失误链的形成，在此认识基础上，采取相应的措施来终止事件链。

Identification(识别)

B67Signs(迹象)

Thesignsindicatingtheformationofanerrorchainarethesameasthesignsindicatingthelossofsituationawareness.

表明失误链形成的迹象与丧失情景意识的迹象是一样的。

ThuswiththelossofSituationalAwarenesscomestheformationofanErrorChain.

因此，丧失情景意识致使失误链得以形成。

Signs(迹象)

Thesignsin68SignsforIndicatingtheFormationofanErrorChain(表明失误链形成的迹象)

A.Ambiguity不确定性B.Distraction注意力分散C.Feelingofinadequacyorconfusion感知不全面或混乱D.Communicationbreakingdown通信中断E.ImproperCONNorlookout指挥或监测不当F.Departurefromconditionplan偏离设定工况G.Violationofestablishedrulesorprocedures违反已建立的规则或程序H.Complacency自满SignsforIndicatingtheForma69A.Ambiguity不确定性

When2ormoreindependentsourcesofinformationappearstodisagree当二种或二种以上单独的信息源产生矛盾时:People人员Equipment设备Rules,regulations,procedures,systems法规、规则、程序与系统Oranycombinationofthese或其他合成的来源A.Ambiguity不确定性

When2ormo70Ambiguityitselfmaynotbedangerous,butitmeansthatthereisadifferenceandthecauseofthisdifferenceneedstobeverified.Ambiguitymaybearesultofinexperienceorlackoftraining.不确定性本身也许不危险，但它意味着有差异，但差异原因需要证实。不确定性也可能是经验不足或缺乏训练的结果Ambiguityitselfmaynotbe71B.Distraction注意力分散

Distractioncanbecausedby:

注意力分散可由下列因素造成：BreakdowninLeadershipandManagementskills领导与管理的失误；

excessiveworkload/stress/fatigue超负荷工作/压力/疲劳；emergencysituations紧急情况；

inattention注意力不集中；

inexperience经验不足。B.Distraction注意力分散

Distra72Focusofattentionononeinputorcomponentofsituationalawarenesstotheexclusionofothers，suchasatellcall,whichcanoccupythefullattentionofapersontotheexclusionofothermoreurgentneeds.Itisanotherformofthedistraction.

注意力集中在一个问题或情景意识的某一方面，例如电话呼叫，它可吸引一个人的全部注意力，从而忽视了处理其它更紧迫的事件从而忽视了其它情况。这是注意力分散的另一种形式。Focusofattentiononone73C.FeelingofInadequacyorConfusion

感知不全面或混乱

Afellingoflossofcontrolofthesituationsuchthatthepersonconcerneddoesnotknowwhatisexpectedtohappennext.Frequentlytheresultoflackofexperience.

对失去局面控制感的人员是不知道随后将会发生什么的。这往往是由于经验缺乏造成的。

Asenseofuncertaintyorconfusionaboutasituationcausedbylackofprofessionalintuitionandcognitivedissonance

对局面难以确定和发生感觉混乱通常是缺乏职业的直觉和认知不清而发生的。C.FeelingofInadequacyorCo74D.CommunicationBreakingDown

通信中断

Internalcommunicationsmaybeconfusedbyphysicalcausessuchasnoise,etc.orbecausedbylackofacommonlanguageordifferingproceduralmethods.Externalcommunicationsbreakdownmayalsobecausedbyanon-commonlanguageorplainmisunderstanding.

船内通信可能被物理因素所干扰，例如噪声等。也可能因缺乏共同语言或不同的处理方法而中断。外部通信的中断可能是没有共同语言或误解造成的。

D.CommunicationBreakingDown75Improperorpoorcommunicationswhichresultin：不正确或不良的通信将导致:Directionsnotbeingexecutedproperly指令不能被正确执行；Theneedforrepetitionofdirections.要求重复指示；MissedMessages丢失信息；Incompleteacceptanceorunderstandingoftheplan

不能完整的接受和理解计划。Improperorpoorcommunication76E.ImproperCONNorlookout

指挥或监测不当

Improperconningandpoorlookoutmaybearesultoflackofsituationalawarenessaswellasanindicationofitsbreakdown.

指挥或监测不当可能是由情景意识不够，也意味着错误的表现。

E.ImproperCONNorlookout

77Forexamples例如:Notexercisingappropriatecontrolanddirection.未能加以适当的控制与指挥

Excessivespeed超速；

Improperoperationoftheengine机器不正确的运行.

Notstationingappropriatelookouts未能安排好监测人员

Insufficientqualifiedpersonnelforthetaskat

hand身边能胜任工作的人员不足。Forexamples例如:78F.DeparturefromConditionPlan

偏离设定工况

DeparturefromthePlanedconditionmaybearesultimproperconningorimpropermonitoringoftheoperationoftheengine.

偏离设定工况可能是由于在机器运行中的指挥或监控不当而造成的。F.DeparturefromConditionPl79Notbuildinganddisseminatingtheconditionoftheengine未制定或落实好设定工况；Unplanned/undresseddeparturesfromaconditionoftheengine未能计划和造成对设定工况的背离；Failuretomeetthegoalsandtargetsofanestablishedplanwithoutfollow-up未能采取进一步的措施达到已制定计划的目的与要求。Notbuildinganddisseminatin80G.ViolationofEstablishedRulesorProcedures违反已建立的规则或程序

Departurefromclearlydefinedrulesandstandardoperatingprocedureswithoutjustification，suchas:Rulesoftheportauti-pollution,EngineProcedures,Engineeringoperationandcompanypolicy

没有正当理由而背离明确规定的规则和标准操作程序。例如：港口防污规则、机炉舱规则、轮机操作程序和公司政策等。G.ViolationofEstablishedRu81

H.Complacency自满

Overconfidence过于自信；Over-familiaritywiththerouteorthetaskathand对手中工作与任务过于熟悉；Ignoringorbelittlingpotentialproblems不考虑和轻视潜在问题；Beinglulledintoafalsesenseofsecurity自我认为很安全。

H.Complacency自满

Overconfiden82Whatcancauseerrors?

哪些因素会产生过失?

Therearemanycombinationsandwaysinwhicherrorscanoccur,bothtechnicalerrorsofshipandhumanerror.

过失的产生因素有多种，包括船舶的技术性故障和人为失误。

Whatcancauseerrors?

哪些因素会产生83TechnicalErrorsofengine

（机器的技术性故障）

涉及到机器运行的主要技术参数超限报警，如未被发觉，将导致机器处于失控的状态，从而进一步引起更大的故障。Referredtothemachinelimitexceedingalarmofmaintechnicalparametersinrunning,ifnotnoted,itwillleadtowildconditionandcauseseverertroubles.TechnicalErrorsofengine

（机器84ErrorsfromEquipmentandInformation因设备与资料产生的失误

Totalorintermittentfailure完全故障或间歇性故障Malfunctionofsafetysystemsandalarms安全系统和报警故障Misleadinginformationfromuncalibratedinstruments从未标准化的设备获得的错误信息Improperofsystemduetoanunturnedequipment由于某些设备未开启动而造成系统不正常Outofdateinformationonpapersandinstraction图纸和说明书上的错误信息ErrorsfromEquipmentandInfo85HumanBeings（人）

Humanbeingsarenotmachines人非机器Humansaregoodatassessingthesituationapplyingknowledgeandsolvingproblems.

Humansarebadatsustaininglongrepetitivetasks,concentratinghardforlongperiodswithoutabreak,aresubjecttotirednessandfatigueandthedullingeffectsofboredom.

人擅长于应用知识来分析局面，解决问题。人不擅长于长时间进行重复工作和长期不间歇地保持精神高度集中，易于因厌烦、疲劳和枯燥而产生迟钝。

HumanBeings（人）

Humanbeingsa86Forthehumanerrors,itispossiblethatanoperatormaymakeamistake.对于人为过失而言，它可能是指操作者也许会犯错误。ThismightbetheMMwhooperatesthewrongcourse,ortheOEWwhomakesanerror,orChiefengineerdecidewrongly.它可能是机工操作失误、值班轮机员管理不当或轮机长决策错误。Forthehumanerrors,itispo87KindsofHumanError

人为过失的种类UnintentionalActionIntentionalActionUnsafeAct&DecisionSlipsLapseMistakesViolationSkill-BasedAttentionalFailure&MemoryFailureRule-Based&Knowledge-basedMistakeKnowledge-basedRoutise&ExceptionalAdapationsBasicErrorTypesKindsofHumanError

人为过失的种类Un88KindsofHumanError

人为过失的种类KindsofHumanError

人为过失的种类89KindsofHumanError

人为过失的种类

A.Slipsandlapses疏忽和差错

B.Rule-basedmistakes基于法规的错误

C.

Knowledge-basedmistakes基于知识的错误D.CulturalConditioning文化制约

E.Violationofsafepractices违反安全惯例

KindsofHumanError

人为过失的种类

90Slips&Lapses

疏忽和失误

Distractionandpreoccupation

注意力分散和偏见

Changestonormalexpectedcircumstances

正常可预见环境的变化

Stressandfatigue

压力和疲劳

Slips&Lapses

疏忽和失误

Distr91KindsofHumanError

人类错误的性质

A.Knowledge-BasedMistakes基于知识的错误;B.Rule-basedMistakes基于法规的错误；C.Skill-BasedMistakes基于技能的错误；D.CulturalConditioning文化的制约；E.ViolationofSafePractice违反安全惯例。KindsofHumanError

人类错误的性质A92A.Knowledge-BasedMistakes

基于知识的错误

Realweaknessduetoignorance

由于无知而犯错Overconfidenceduetoignorance

由于无知而自负Amistakenunderstandingoftheprinciplesinvolved

有关原则的理解错误A.Knowledge-BasedMistakes

93B.Rule-basedMistakes

基于法规的错误Makingaquickdecisionwithoutconsiderationoftherules；

没有考虑法规而草率决定；Notnoticingwhenaruledoesnotwork；

没有注意到法规不适用；Misapplyingtoshortcutrules；

错误应用“简化的”法规；

Makingerrorsfromambiguousinformation；由于信息不明确而犯错。B.Rule-basedMistakes

基于法94C.Skill-BasedMistakes

基于技能的错误Lackofthetraining

缺乏训练Notexchangeoftheexperience

不交流经验LessPracticalOperation

实际操作过少C.Skill-BasedMistakes

基于95D.CulturalConditioning

文化制约

Culturalconditioningcancauseembarrassmentinthecommandstructurefoundonboardships.文化制约在船上的指挥结构中会造成问题。

Someculturesreinforceanacceptanceofauthoritysothatitisverydifficulttoquestionseniorofficerswithoutfeelinguncomfortable.有些文化可加强对权威的认可，以致质询高级船员时因感到不自在而变得十分困难

Otherculturalinfluencesincludepossiblemisunderstandingsofintentionsandawillingnesstocomplywithoutquestion.其他文化影响包括可能对意图的误解和毫无疑问地服从。D.CulturalConditioning

96E.ViolationofSafePractice

违反安全惯例

-Complacency自满

-Apathyleadingtolazinessratherthancompliance冷漠导致懒惰而不是遵守；

-Experimentation凭经验；

-Adesiretopushlimitsratherthancomply被迫执行而不是出自意愿的遵守；

-Motivationalandbehavioralproblemsindividuallyandintheteam个体或团队的动机与行为问题E.ViolationofSafePractice

97

-Sometimescomplacencymeansoverconfidence有时自满意味着过于自信-Itincludestheneglectadvicefromothers

它包括忽视别人的建议，

-Neglecttoconsulttobooksorpublications

忽视查阅书或出版物

-NeglecttoconsulttoRulesandRegulations

忽视查阅法规

-Departurefromconditionplan

偏离设定工况

-Sometimescomplacencymea98BreakingtheErrorChains

破断失误链(1)

-Recognizingthepossibilityoftheerrorchainandrelevantlinkages认识失误链与相关的环节存在的可能性-Identifyingofexistingerrorchainandrelevantlinkages辨清现有失误链及其相关的环节-Takingactiontobreaktheerrorchainandmakingpropermeasuretopreventtheoccurrenceoferrorchainagain.采取行动破断失误链并制定防止失误链的再次产生。-