重大職業災害的人因工程風險評估

Human Factors / Ergonomic Risk Analysis of Major Occupational Accidents

我國重大職業災害中，因作業場所未設置適當之防護設備、未考量安全操作的機械設計、人員的不當操作及未設置警報裝置等人因工程設計不良而誘發或導致的案例每年層出不窮。本研究透過2013年至2018年，我國不屬營造業之一般行業重大職災案例進行分析，找出有關人因工程設計不良之案例，並探討案例中人因工程設計不良之致災原因。針對237件重大職災個案利用「人為因素分析與歸類系統（Human Factors Analysis Classification System， HFACS）」與「人因工程檢核（Ergonomics Checkpoints， EC）」進行肇因分析，75.3%個案和事故人的（第一層次）個人不安全的行為有關，27.4%個案和所處的不安全個人、作業及環境（第二層次）關聯，52.4%事故可歸諸管理的督導及支援問題（第三層次），33.8%個案和影響最大的公司組織運作及文化（最高層次）相關。

"More than 300 cases of major occupational disasters occurr yearly in Taiwan. Human errors, machine/equipment with poor engineering design, workplace lack of protection, wrongly handled materials, improper methods of operation, and poor environmental controls were at fault for the occurrence of these accidents. This study developed a checklist for risk factor analysis based on the integration of the Human Factors Analysis Classification System (HFACS) and the Ergonomics Checkpoints (EC). After examining the root causes of a sample of 237 major occupational accidents, it was identified that 75.3% of cases were related to unsafe acts of operators, 27.4% were the result of the preconditions for unsafe acts, 52.4% were related to unsafe supervisions, and 33.8% were due to organizational factors."