대한인간공학회 2015 년추계학술발표회 2015 년 10 월 15~16 일, 부경대학교, 부산 3.0 A Concept and Application of Human Error 3.0 for High-Reliability Era Yong-Hee Lee I&C and Hu

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1 3.0 A Concept and Application of Human Error 3.0 for High-Reliability Era Yong-Hee Lee I&C and Human Factors Div. KAERI 대전광역시유성구대덕대로 , ( ), (,,, ),,,,, ( 3.0 ) * : 3.0(human error 3.0), (rare error), (countermeasure), (nuclear safety), (organizational factor), (safety culture) 1., - 1) 연락처 : ( ) ( 3.0 ), (cause) (countermeasure),, , (Meister 1967, McCormick 1972) ,,, 2.0 (Rasmussen 1992, Hollnagel 1996, Reason 1997, Lee 2006). Errors Human Failure Violations Slips Mistakes Routine Exceptional Skill Based Rule Based Knowledge Based 그림 1. 인적오류의심리학적유형분류 (Reason) Reason (slip),. 분류 공통적오류성향 심리적결함 인적오류유발세부현상의예시 능력한계에육박하는것은회피한다너무쉬운것은동기부여가안된다변화를싫어한다. 복잡한것은생략하려한다추가적인일에대해알아서수행하지않는다. 전체에미치는영향에대해둔감하다변경된시설절차 / 규정 / 환경을고려하지않는다간접경험을적극적으로활용하지않는다훈련및규정에의해주의력이유지되지않는다집단및개인심리현상에취약하다 자기귀인 : 무조건내탓으로돌리기다수 ( 집단 ) 불패 : 우리모두 ( 다수 ) 가틀릴리는없다책임분산 : 여럿이면결과의심각성도줄어든다. 자기장애화 : ~ 만아니라면하고자기핑계를찾는다운명론 : 이정도의오류는어쩔수없다. 전이행위 : 꿩대신닭 스트레스를잘못된행동으로푼다. (lapse), 2.3-2, 신입작업자 -계획대로수행하지못한다 -정보과잉으로혼란에빠진다 -정보의통합및분리처리가어렵다 -기억량이적고제때기억나지않는다 -의사결정이지연되고어렵게수행된다 -선택가능한대안이너무적거나많다 -늦고매끄럽지못하므로분주하다 -순서가혼란스럽다 -정신적신체적시간적여유가없다 -회복이어렵다 숙련작업자 -수행과정에서즉흥적으로적당히수행한다 -습관적인방식을따른다 -개인적판단으로특정한정보나억측을활용한다 -오류를감지하거나회복하지못한다 -예외적인요소에대한인식을빠뜨린다 -여유시간이과도하게많다 -각성수준이낮다 -계획대로수행하려는의지가낮다 -외부설명이나의사소통이어렵다 -자기확신으로인한심리적위험에취약하다 2.0 (cause) (symptom) (event) ( - )

2 2.0 ( 2003, 2007, 2014) 2.0 ( ) 2.0 ( 2014) ü Human Error accident does NOT happen Accidently ü Human Error is NOT an Error of Human alone ü Human Error is NOT a problem of Performance in average ü Human Error is NOT a primary concern of Human-in-the-Loop ü Human Error is NOT captured by Statistics itself ü Human Error is NOT limited by a limited system/system limitations ü Human Error is NOT totally suppressed by Enforces/Training/Cautions ü Human Error is NOT prevented by Himself to conduct it (Lee et al. 1999) ü Human Error is NOT explained in ONE way (Rasmussen 1990) ü Human Error is NOT repeated by the same cause ü Human Error is NOT identified by the same consequence ü Human Error is NOT effectively prevented by Eliminating the Cause, ICT (organizational factor), (safety culture),, (rare),, , (2015 ) (1) 그림 3 인적오류영향요소 (A. Swain 1983) (accidently) (accident) ( ), ( ), (slip) (lapse) (stochastic), HRA.,,, (2), Reason, (, 2012, 2014), (rare) ( 2011, 2014), (skill-based), (rule-based), (knowledge-based),. (organizational factor) (tightly-coupled), (looselycoupled), (rare), (proactive) ( ), (funadamental surprise), (3), 2.0

3 ,. (hindsight effect),, ( ), (4) (enforcement) / /,,, ( ) ( ),,, X Y,,,, (system-induced error) (5) ' '? (cause),, / (tightly-coupled),, (6) ' ' (performance),,,.,

4 Ÿ - Ÿ - Ÿ. - Ÿ -, Ÿ - (1) -,,,,, (slip lapse), (criteria principle) (control) (enforcement),,, (avoidance) (large system) (complex system) (high-reliability system) (tightl y-coupled) (technical system) (irreversible) (non-injury safety) (latent hazard) (out-of-the-loop) (2) 3.0 (basic attribute) ( 2003, 2006, 2011). - (dependancy on situation), - (chained structured-ness) - (representativeness of latency) 3.0 Ÿ, Ÿ, Ÿ,,, (3) (system safety) (Lee, 2006)., (Kim et al, 2014) 2 (hazards). (Lee, et al, 2008) Y, (slip).,, S,,,,,,,,,,, (safety culture),

, IAEA, NRC, NEI, (violation), (avoidance), (sabotage) (competence), (statistical approach) (rare event) /,, (injury loss) (system loss),, (large) (complex),,, (tightly-coupled system), (multiple

0 주안점 작업자의행위 ( 실수 ) 차원 Fails in Human Behav.

5 , IAEA, NRC, NEI, (violation), (avoidance), (sabotage) (competence), (statistical approach) (rare event) /,, (injury loss) (system loss),, (large) (complex),,, (tightly-coupled system), (multiple barriers) (safety feature) - (cause-consequence), 5. ICT (rare),, (organizational factor) (safety culture) ( 3.0 ),, 3.0 ( 2.0), (cause) (countermeasure) (Cause-and-Consequence) 인적오류 주안점 작업자의행위 ( 실수 ) 차원 Fails in Human Behav. 체계의인적요소위험성관리- Human Caused/Induced System Failure 선행적대처가능성포착 System Fail including Human Factors 관련개념 전통적산업안전기능적완수 : 직무설계절차서, 훈련 TMI 사고이후수행도형성요인 (PSFs) -> 인적오류유발요인위험대처 : 인터페이스개선등 체르노빌 / 후쿠시마사건에서인적요소대처 : 사고 / 고장에대한선행적대처능력 Resilience Engineering 3.0,, Acknowledgements This research was supported by the nuclear energy research and development project (Grant. 2012M2A8A ) funded by the Ministry of Education, Science and Technology. 6. 참고문헌 (1) 이용희외, 원자력인적오류대처기술개발 : 1 단계보고서, 한국원자력연구원, (2) 이용희, 중대산업사고예방활동촉진을위한효과적인인적오류대응방안, 산업안전보건제 15권 10호, 15(10), (3) 이용희, 인적오류연구기술현황 : 무엇이며어떻게대응할것인가? 대한인간공학회지인적오류특집호 30(1), pp.1-8, (4) 이용희, 오연주, 신광현, 장통일, 이정운, 윤종훈, 박재창, KAERI/TR-4575/2012, 디지털기기의인적오류평가기법개발및활용, 한국원자력연구원, (5) 이용희외, 가동원전의인적오류예방활동및기법, 대한인간공학회지 30(1), pp.75-86, (6) 이용희, 원자력인적오류대처기술개발 : 동향과방향, 원자력인적요인워크샵 : 원전인적행위조사분석활성화, 한국원자력연구원, (7) Lee, Y. H. and Yoon, J. H., A study on the effect of the coincidences between group traits and personal traits upon the job stress, J. KISE, 35(2), pp19~27, (8) Lee, Y. H., A Strategic Enhancement of the Personnel Competences for the Safety Culture of NPPs, Proc. ESK-2013 Spring, (9) Lee. Y. H., A Review on the Effective Countermeasures to the Recent Human Errors in High- Reliability Industrial Systems, Proc. ESK-2014 Fall, (10) IAEA, The Fukushima Daiichi Accident: Technical Volume 2/5 Safety Assessment, 2015.

大韓不姙學會誌 : 第 27 卷第 4 號 2000

大韓不姙學會誌 : 第 27 卷第 4 號 2000 안전문화의인간공학적접근방안에대한논의 A Study on the Human Factors Engineering Approach to Safety Culture 이용희 (Yong-Hee Lee) 한국원자력연구원 Korea Atomic Energy Research Institute (KAERI), Daedeok-daero 989-11, Yuseong-gu, Daejeon,