国内图书分类号：F273.2; TL38+2 学校代码：10213
国际图书分类号：614.8 密级：公开
工商管理硕士学位论文
红沿河核电站人因失误事件预防管理研究
硕 士 研究生： 高祯铎
导师： 钱国明副教授
申 请学 位： 工商管理硕士
所 在单 位： 辽宁红沿河核电有限公司
答辩日期： 2017年6月
授予学位单位： 哈尔滨工业大学
Classified Index: F273.2; TL38+2
U.D.C.: 614.8
A Dissertation for the Degree of MBA
RESEARCH ON THE PREVENTIVE
MANAGEMENT OF HUMAN FACTOR
EVENT IN HONGYANHE NUCLEAR
POWER PLANT
Candidate：Gao Zhenduo
Supervisor：Associate Prof. Qian Guoming
Academic Degree Applied for： MBA
Affiliation：Liaoning Hongyanhe Nuclear Power
Co., Ltd
Date of Defense：June, 2017
Degree-Offering-Institution： Harbin Institute of Technology
哈尔滨工业大学工商管理硕士学位论文
- I -
摘要
国内外核电站的运维经验以及相关研究指出，人因失误是核电站安全事
件最重要的诱发因素之一。要是能从自身核电站的人因失误事件中吸取经验，
并结合其他核电站的经验反馈，针对红沿河核电站人因失误事件预防管理体
系采取相应的改进措施，就能减少人因失误事件的发生的可能性，从而提高
红沿河核电站运行的安全性
本文的研究过程，是以红沿河核电站运行期间的人因失误事件及其他核
电站的经验反馈为研究对象，以完善红沿河核电站人因失误事件预防管理体
系为研究目标。运用人因可靠性研究和核电站安全事件根本原因分析方法，
分析了红沿河核电站运行以来部分典型人因失误事件的直接原因和根本原
因，对红沿河核电站现行人因失误事件预防管理体系做出评价。运用归纳分
析的方法从其他核电站人因失误事件分析得出核电站人因失误事件的特点，
总结出人因失误事件形成机理及主要影响因素，分析得出红沿河核电站人因
失误事件预防管理体系可能存在的潜在风险。针对红沿河核电站的实际情况，
提从人员、环境、文化制度三个方面给出针对辽宁红沿河核电站人因失误事
件预防管理体系的具体完善建议
通过本文的研究，归纳总结了核电站人因失误事件的特点，探究了核电
站人因失误事件的产生机理和主要影响因素；同时通过对辽宁红沿河核电站
人因失误事件预防管理体系的评价以及可能存在的潜在风险，提出针对红沿
河核电站的完善建议，对今后红沿河核电站的人因失误事件的预防管理具有
积极意义
关键词：红沿河核电站；人因失误；预防管理
哈尔滨工业大学工商管理硕士学位论文
- II -
Abstract
According to the experience and research of the nuclear power plant
operation, human factor event is an important factor that affects the NPP safety.
If we can learn from the events which have already taken place and take the
proper improved measures, recurrent of such events can be prevented.
Accordingly, the safety and economy will be improved.
In the research, the human factor event during the operation of Liaoning
Hongyanhe NPP has been taken as the study case with the aim of preventing
human error efficiently. The theory of human management, the method of
fundamental human factor event analysis and the method of induce analysis have
been applied, together with the human factor event management practice, to
analyze the main reasons for human factor events during the operation of
Liaoning Hongyanhe NPP. Based on the main reasons for human factor events
and specific condition in Liaoning Hongyanhe NPP, several specific suggestions
of improvement on the preventive management of human factor event in
Liaoning Hongyanhe NPP has been offered in this paper, from following four
aspects, personnel, surroundings, system and culture.
This dissertation consists of the characteristics and fountainhead of human
factor event, the exploration of influencing factors of human factor event. Also,
targeted improving measures have been presented through the analysis and
sum-up of root factor of human factor event in Liaoning Hongyanhe NPP, which
will benefit the preventive management of human factor event, the safety
assurance of NPP operation as well.
key words: Hongyanhe NPP, human error, preventive management。