基于认知模型与故障树的核电厂严重事故下人因失误分析

为分析核电厂应急人员在处理严重事故时可能发生的人因失误，通过建立不同应急人员的认知模型及识别相应的行为影响因子，在认知功能的基础上识别出13种人因失误模式:信息来源不足、信息可靠性不佳、过早结束对参数的获取、重要数据处理不正确、缓解措施负面影响评估失误、选择不适用当前情景的策略、延迟决策、遗漏重要信息/警报、延迟发觉、软操作失误、信息反馈失效、设备安装/连接/操作失误、延迟实施，并基于故障树分析得出人因失误模式的主要根原因:交流失效、时间压力、事故发展的不确定性、信息接收延误、监视失误、人-机界面不佳和环境因素。分析结果可用于预测严重事故缓解进程中可能出现的人因失误，为核电厂实施严重事故管理和技术改进，以及保障严重事故工况下核电厂安全提供参考。 

Analysis of Human Errors in Severe Accident of Nuclear Power Plant Based on Cognitive Model and Fault Tree

In order to analyze the human errors of the emergency crews in nuclear power plants while dealing with severe accidents, this paper establishes a cognitive model of the emergency crew, identifies the corresponding performance influencing factors, finds thirteen human error modes, known as insufficient information source, poor information reliability, premature end of parameter acquisition, incorrect processing of important data, error in negative impact assessment of mitigation measures, selection of strategies unsuitable for the current situation, delayed decision-making, omission of important information / alarm, delayed detection, soft control operation error, information feedback failure, equipment installation, connection or operation error, and delayed implementation. Then the paper analyzes the root causes of human errors based on fault tree, including communication failure, time pressure, uncertainty of accident progress, information delayed reception, monitoring error, poor human-computer interface and environmental factors. The results can be used to predict the human errors in the process of severe accident mitigation, as well as helping the implementation of severe accident management and the technical improvement, thus providing guidance for improving the safety of nuclear power plants in severe accidents.