臺灣博碩士論文加值系統

本研究欲找出導致職業災害之人為因素，蒐集個案公司於2011~2015年間所發生39件職業災害事故調查報告。從個案公司之職災發生條件進行統計以及透過「人為因素分析與歸納系統(Human Factors Analysis and Classification System；以下簡稱HFACS)」歸納分析方法得到以下六項結果：
1、最容易造成人體上肢部位受傷共計發生31件(佔79.49%)。
2、下半年度發生事故頻率(佔64.1%)高於上半年度事故頻率(佔15.38%)；以職災事故5種傷害類型，其中就以切割傷發生19件(佔48.72%)、夾捲傷發生11件(28.21%)最多。
3、以HFACS理論分析因人為失誤引發事故共384次， 而屬於層級一顯性失誤者達110次(28.65%)；層級二屬於隱性失誤達145次(37.76%)。
4、不安全的行為(層級一)的4個子項目中，以決策判斷錯誤37次(33.64%)及技術操作錯誤35次(31.82%)最高，是造成職業災害最為主要的顯性失誤因素。
5、不安全前置狀況(層級二)的7個子項目中，以個人準備狀況38次(26.21%)、不佳的心智狀態36次(24.83%)及生理的心智的極限30次(20.69%)等引發次數較高，是職業災害中的隱性失誤最主要原因。
6、職災事故發生後利用HFACS理論之最大的優點，乃是能夠顯示出於事故者本身、作業行為、專業技能及違反廠內安全衛生規定等條件進行檢討，可追溯其於顯性及隱性失誤引發事故之因素。

關鍵詞：職業災害、事故調查、人為因素分析與歸納系統

In this article, its purpose is to find the human factors of leading to the cause of occupational accident, and we collect thirty-nine investigated reports of occupational accident from 2011 to 2015 in a cooperative company. For occurred occupational disaster of the cooperative company, we use HFACS (the abbreviation of Human Factors Analysis and Classification System) to complete inductive analysis of conditional statistics and the following six meaning results are obtained.
1. For injured parts of their bodies of injured employees, there are thirty-one injured employees with spots of their upper limbs that account for 79.49%.
2. There are five reasons to cause occurrence of occupational accident of employee, occupational accidents of nineteen employees that account for 48.72% are to be cut, occupational accidents of eleven employees that account for 28.21% are to be clamped, and the frequency of occupational accident of the rear half year that accounts for 64.1 % is higher the frequency of occupational accident of the front half year that accounts for 15.38%.
3. By means of using theoretical analysis of HFACS, there are 384 occupational accidents caused by wrong operations of employee, the reason of occurrence for 110 occupational accidents that account for 28.65% belongs to the active failure and the reason of occurrence for 145 occupational accidents that account for 37.76% belongs to the latent failure.
4. Based on four items of unsafe acts, there are 37 decision errors that account for 33.64% and 35 skill-based errors that account for 28.65%, so they become the main reasons of causing obvious occupational accidents.
5. Based on seven items of preconditions for unsafe acts, there are 38 cases of personal readiness that account for 26.21%, 36 cases of adverse mental states that account for 24.83% and 30 cases of physical/mental limitations that account for 20.69%, so they become the main reasons of causing latent failure occupational accidents.
6. After occurrence of occupational accident, we can use those theories in HFACS to find the possible reasons of active and latent occupational accidents in light of employee himself, operational behavior, the specialized skills and whether they violate the safety and health of the cooperative company to stipulate and so on.

Key words: Occupational accident, Accident Investigation, Human factors analysis and induction system

摘要 i
Abstract ii
致謝 iv
目錄 v
表目錄 vii
圖目錄 viii
第壹章 緒論 1
1.1 研究背景與動機 1
1.2 研究目的 2
1.3 研究範圍與限制 3
1.3.1 研究範圍 3
1.3.2研究限制 3
1.4 研究架構 4
第貳章 文獻回顧 5
2.1 職業災害之概念 5
2.2 人為失誤的範圍 7
2.2.1人為因素 7
2.2.2人為失誤相關概念 8
2.3 人為因素分析與歸納系統 12
第叁章 研究方法 19
3.1 研究對象 19
3.2 事故調查報告 20
3.3 HFACS分類架構 21
3.4 研究流程 25
第肆章 結果與討論 26
4.1 樣本案例敘述 26
4.2 樣本分析 27
4.3 運用HFACS系統歸納人為失誤 37
4.4小結 45
第伍章 結論與建議 48
5.1 結論 48
5.2 建議 49
參考文獻 51

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