<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">1.</SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">运行人员是有组织的<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">在社会技术系统中，将运行人员的差错作<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">为事故发生的根源是不客观的。这是因为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">运行人员不是孤立工作的，他们是组织的<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">组成部分，在一定的社会环境中，按组织<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">授权和分工，有计划、有目的工作。此<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">外，运行人员并不是在真空中工作。他们<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的行为和态度是组织及其代表的反映。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">2</SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">．组织机构的两个要素人和技术相互作用<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">社会技术系统中的组织机构，由于人与技术的相互依赖<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">性，其结果是在社会技术系统中可能时常发生复杂和被<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">忽视的变化。因此，在寻求这些系统的安全改进措施<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">时，单从技术方面或只从行为科学（即人为差错）方面<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">寻找安全缺陷或事故发生的原因，其范围太窄且具有局<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">限性。对技术系统中重大事故的分析已清楚表明，灾难<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">发生的前提可追溯到可确认的组织缺陷上。通常发现大<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">量引起事故发生的意外事件具有一个按年计算的“潜伏<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">期”，<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">在航空系统中，组织包括：<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">航空公司和其它营运人、制造厂、机场、空中交<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">通管制、气象服务、民用航空当局、安全调查机<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">构、国际组织（国际民用航空组织<SPAN lang=EN-US>ICAO</SPAN>、联合航<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">空局<SPAN lang=EN-US>JAA</SPAN>、欧洲空中航行安全局<SPAN lang=EN-US>EUROCONTROL<o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">等）和专业协会（国际航空运输协会<SPAN lang=EN-US>IATA</SPAN>、国<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">际航空公司驾驶员协会联合会<SPAN lang=EN-US>IFALPA</SPAN>、国际空中<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">交通管制员协会联合会<SPAN lang=EN-US>IFATCA</SPAN>、国际航空安全调<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">查员协会<SPAN lang=EN-US>ISASI</SPAN>等）。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">3</SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">．集中解决决策层问题<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">由于技术的不断进步，主要设备故障或操<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">作人员差错很少成为系统安全防线崩溃的<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">根本原因。相反，它很可能是决策者、规<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">章管理人员和在时间和空间上远离事件的<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">其它人员孕育的。安全防线崩溃主要是由<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">于管理阶层的人决策失误造成的。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">二、安全管理理论和方法的新发展<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">1</SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">．<SPAN lang=EN-US>Reason</SPAN>的人为差错</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">“</FONT></SPAN></B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">瑞士奶酪</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">”</FONT></SPAN></B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">模型<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">一种引人关注的人为差错起源分析方法是<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN lang=EN-US style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">James Reason</SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">提出的（<SPAN lang=EN-US>1990</SPAN>）。在“ 瑞士<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">奶酪”人为差错模型中，<SPAN lang=EN-US>Reason</SPAN>将人的失误<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">分为四级， 每一级影响下一级（ 见下<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">图）。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">潜在问题</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">Latent Failures<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">（潜在故障）<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">潜在问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">（潜在故障）<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">潜<SPAN lang=EN-US>______________</SPAN>在的问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">（ 潜在故障）<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">防线被突破或缺少防线<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">组织因素<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全的监督<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的前提<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">摘自</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">Reason (1990)<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">事故和损伤<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">出现的问题</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">Active Failures<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">（主动故障）<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">REASON</FONT></SPAN></B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">模型（</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">“ </FONT></SPAN></B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">瑞士奶酪</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">”</FONT></SPAN></B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">人为差错模型〕<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">因果事故链理论<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">出现的问题<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">扫视仪表出错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">在仅</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">VMC</FONT></SPAN></B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">情况下进入</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">IMC<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">摘自</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">Reason (1990)<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">防线被突破或缺少防线<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">运行系统的失效<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">第一级是操作者的不安全行为，它最终导<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">致了事故发生。这一级通常指飞行员差<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">错，事故调查普遍关注的交点，这样做的<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">结果是使许多事故原因未能揭露出来。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">潜在的问题<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><FONT face="Times New Roman"><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"> </SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt">CRM</SPAN></B></FONT><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">差<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">失去处境意识<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">防线被突破或缺少防线<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的前提<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">Adapted from Reason (1990)<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">出现的问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">扫视仪表出错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">在仅</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">VMC</FONT></SPAN></B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">情况下进入</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">IMC<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">运行系统的失效<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">第二级是不安全行为的前提条件，操作者<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">发生差错一定有主、客观原因。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">潜在问题<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">训练大纲有缺陷<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">机组搭配不当<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">潜在的问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><FONT face="Times New Roman"><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"> </SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt">CRM</SPAN></B></FONT><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">差<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">失去处境意识<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">防线被突破或缺少防线<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的监督<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">的前提<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">不安全行为<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">摘自</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">Reason (1990)<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">出现的问题<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: WingdingsOOEnc; mso-font-kerning: 0pt; mso-bidi-font-family: WingdingsOOEnc"><FONT face="Times New Roman"> </FONT></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">扫视仪表出错<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 方正舒体; mso-font-kerning: 0pt; mso-bidi-font-family: 方正舒体; mso-hansi-font-family: 方正舒体"></SPAN><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">在仅</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">VMC</FONT></SPAN></B><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">情况下进入</SPAN><B><SPAN lang=EN-US style="FONT-SIZE: 14pt; mso-font-kerning: 0pt"><FONT face="Times New Roman">IMC<o:p></o:p></FONT></SPAN></B></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">运行系统的失效<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">第三级是不安全的监督，基层管理人员对<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">操作者缺乏良好的专业指导和监督，事故<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">隐患将明显<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">上升。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">运行系统的失效<SPAN lang=EN-US><?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">第四级组织因素，组织因素会影响各级<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">人员的表现。如果在当前水平上大大降<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">低事故率，必须调查和分析事故发生的<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">整个过程，将组织内部各个层面上的事<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
<P class=MsoNormal style="MARGIN: 0cm 0cm 0pt; TEXT-ALIGN: left; mso-layout-grid-align: none" align=left><SPAN style="FONT-SIZE: 14pt; FONT-FAMILY: 宋体; mso-font-kerning: 0pt; mso-bidi-font-family: 宋体; mso-hansi-font-family: 'Times New Roman'">故原因纳入其中。<SPAN lang=EN-US><o:p></o:p></SPAN></SPAN></P>
