其他摘要 |
The aim of this thesis is to explore the organizational errors in nuclear power stations and civil aviations. It consists three main parts: (1)pilot study, (2)reanalysis of the accident according to the accident report, (3)interview of the pilot, controller and maintenance persons of the civil aviations.
The coding technique, a qualitative method is used in this research. The basic process of it is to determine variables according to the transcriptions of the accident reports or interview; and then determine each variable's scope of variance, and at last form the related coding book. Each transcription was coded by the three coders independently, and then was checked together. Differences were discussed and resolved with the majority rule.
The pilot study consists two parts. One is the semi-construct interview, with 15 employees of a nuclear power station were interviewed. The other is focus group interview. Seven subject matter experts from nuclear power, spaceflight, civil aviation, chemical industry, and petrochemicals industry attended the interview. The focus of the interview is also about the organizational errors, including Chinese reality and ideal. Then the further researches and hypotheses can be determined.
The materials of the reanalysis are nuclear power accident reports. Three experts were asked to judge the organizational errors according to’ the coding book and accidents description. Three other experts were asked to tell if the accidents were well handled, if yes, the accident is successful or is unsuccessful, and the results were used as criteria.
There are 78 interviewees from two civil aviation companies, two control center,and one aircraft maintenance company. including 28 pilots, 33 controllers, 17 maintenance persons. Criteria data is from the statistic data of Civil Aviation
Administration of China and the appraisal of the pilots.
The results are as the following:
1 Through cluster analysis, got five organizational errors in nuclear power field, technical control factors, non-technical factors, information interface, organizational planning, lack of holistic thinking.
2 According to the reanalysis, successful accident represented good technical supports. The immature non-technical factors' contributing effect is relatively more than the mature technical control factors'.
3 According to the coders' subjective judge, got three organizational errors in civil aviation field: technical control- factors, non-technical factors, information interface.
4 Comparing to the maintenance persons, the pilots are more strict with the
departure standard of the aircraft.
5 The controllers will consider the role of their job as "controller", and pilots will look the role of the controller as control service or service. |
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