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”（书作者）列出了50个问题，可在任何人为失误调查过程中用作指导。这些问题的目的是更好地了解与所调查问题相关的人为因素。这不是一份简单的清单，应该与常规的根本原因分析工具（如因果图和故障树分析）一起使用。这些问题的答案将为以下调查要素提供有价值的信息：

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Identifying contributing root causes

找出根本原因

●

Identifying situational factors

确定情景因素

●

Identifying latent factors

识别潜在因素

●

Identifying absent or insufficient control barriers

确定缺少和不充分控制屏障

Classification of Human Errors/Violations

人为失效/违规的分类

1.

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

此人是否无意识地错误执行了任务（委托错误）？

2.

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

此人是否无意识地漏掉了任务或任何步骤（遗漏错误）？

3.

If this was a documentation omission, is the record designed to identify omissions easily?

如果是文件有遗漏，设计的记录是否便于识别遗漏？

4.

Did the person fail to recognize a defect, message, signal, and so on (recognition error)?

此人是否未能识别缺陷、信息、信号等（识别错误）？

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导书规定的方式执行任务？

Procedure Quality and Content

程序质量和内容

6.

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

是否有执行这项任务的正式（书面）指导书？

7.

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

执行任务的邻近区域是否有程序或工作指导书？

8.

Did the procedures or work instructions change recently?

程序或工作指导书最近是否有变更？

9.

Did the person read the procedures or work instructions while executing the task?

此人在执行任务时是否阅读了程序或工作指导书？

10.

Did the procedures or work instructions use specific details rather than a qualitative description (slowly, soon, few, well, and so on)?

程序或工作指导书是否使用了具体细节，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?

执行这项任务需要处理或解释信息吗？

12.

Is there consistency in how other people are performing this task?

其他人执行这项任务的方式是否一致？

13.

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

错误是否与数字或字母信息（规格、批号）有关？

Training

培训

14.

Was the person formally trained on the task or procedure?

该人员是否接受过有关任务或程序的正式培训？

15.

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

培训方法是否适合这项任务？描述所使用的方法。

16.

Does the training cover this specific task?

培训是否涵盖这项具体任务？

17.

How long was the training for this specific task?

这项具体任务的培训时间有多长？

18.

How recently did the person receive the training?

此人最近接受过什么培训？

19.

Who trained this person?

谁培训的这个人？

20.

Who trained the other people who did the task correctly?

是谁培训了其他正确完成任务的人？

21.

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

培训结束后，如何评估有关人员的能力？

22.

Was the training effectiveness evaluated? Describe the method used.

是否对培训效果进行了评估？说明使用的方法。

Situational Factors

情景因素

23.

Are other tasks interrupting the performance of this task?

其他任务是否会干扰这项任务的执行？

24.

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

最近是否对不符合的区域进行过干预？

25.

Were all the area personnel present when the error occurred?

错误发生时，所有区域人员是否都在场？

26.

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

错误发生时，主管或组长在场吗？

27.

Did the error occur during overtime?

错误发生在加班期间吗？

28.

Did the error occur prior to or after a break or shift change?

错误发生在休息或换班之前还是之后？

29.

Did the error occur prior to or after a shutdown or vacation period?

错误是在停机或休假之前还是之后发生的？

30.

Was it a situation with a very tight deadline?

是时间紧迫的情况吗？

31.

Was it a situation of competing priorities?

这是优先事项相互竞争的情况吗？

Latent Factors

潜在因素

32.

Did the person work from memory while executing this task?

在执行这项任务时，他是凭记忆工作的吗？

33.

Was the person working in autopilot mode because he/she was very familiar with the task?

此人是否因为非常熟悉任务而在自动驾驶模式下工作？

34.

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

此人是否在同时执行其他任务（多任务处理）？

35.

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

任务是否需要处理太多信息或同时关注太多事情？

36.

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

这项任务是否要求当事人遵循特定的步骤顺序？

37.

Was the area's layout or workspace overcrowded?

该区域的布局或工作空间是否过于拥挤？

38.

Was the area disorganized, requiring people to have to move around to perform tasks?

该区域是否杂乱无章，需要人们四处移动才能完成任务？

39.

Were the working conditions comfortable (noise, temperature, humidity, illumination [well-lit with bright light], etc.)?

工作条件是否舒适（噪音、温度、湿度、照明[光线充足、明亮]等）？

40.

Is the system or process intuitive enough to be understood easily?

系统或流程是否足够直观，易于理解？

Control Related

相关控制

41.

Is there any control (barrier) in place to specifically avoid this failure?

是否有任何控制措施（屏障）来专门避免这种故障？

42.

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

是否对控制措施进行过质疑，以确定其是否有效？

43.

Are there any job aids or checklists to perform this task?

是否有执行这项任务的工作辅助工具或检查表？

44.

Are their format/contents appropriate for clear interpretation?

它们的格式/内容是否适合清晰解读？

45.

Did the employee use the job aid(s)?

员工是否使用了工作辅助工具？

46.

Does this task include a second person verification or checking?

这项任务是否包括第二人验证或检查？

Skill Fading

技能退化

47.

Is this the first time the person performed this task?

他是第一次执行这项任务吗？

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/她上一次执行这项任务是什么时候？

b. If it’s not the first time, how often does the person perform this task?

b. 如果不是第一次，此人多长时间做一次这项工作？

48.

How many other people do the same task correctly under the same conditions?

在相同条件下，还有多少人能够正确完成同样的任务？

49.

Has the person performed the task correctly earlier?

他之前是否正确地完成了任务？

50.

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

去年发生这种（或类似）错误的频率是多少？