The Analysis Of Organization-Error And Management Measures In Complex-Social Systems

With the development and perfection of technology, the importance of organization and management factors on the Large-Scale and Modern complex human-machinery systems'safety is receiving more attention. Technical errors and individual Human-Error of operators are no longer the ultimate answer to an accident. Organization error has gradually become the focus of attention, and is the new trend of human error study. So, the paper chose the high risk Complex-Social systems to study and analyses the impact of organization factors on system operation security has important theoretical and practical value. The paper is divided into four parts: Organization Error's classification, the format mechanism and performance model of Organization Error, the identification of Organization Error and its Management.Firstly, the article applies AHP to category the Organization Error into five classifications: decision-making failure, management and control failure, technical operation failure, communication failure and defense failure, based on the analysis of basic production elements and structures of the Complex-Social technology system. And then breakdown each category further to establish 26 key indicator elements. Finally, construct a Four-Class model of organization error.Secondly, analysis the mechanism and performance of each Organization Error deeply and then establish the process model of Organization Error's formation and evolution mechanism.Thirdly, on the context of a nuclear power plant's nearly three years internal incidents run report and through the simple gray-level model of Organization Error, the paper applies gray Association theory to obtain associated sequence between each levels'Organizations Error factors: organizational factors which impact system security greatest is technical operation failure, the second is management and control failure; the specific organizational factors which is the largest contribution to the system security is standards and orders failure, the second is the frontline's guide and control failure; the organizational code and norm failure is the largest contribution factor to decision-making failure; system maintenance failure is the largest contribution factor to management failure; the communication content failure is the most impaction to communication failure and the defense mechanism failure is the biggest contribution to defense failure.Finally, the Organization-Error is more complex than individual Human-Error and every factor is interacted and penetrated mutually. If on Organization Error is occur, it may cause any other Organization Error's happen, even leading Chain-Reaction. So the strategies based on Domino-Theory to failure may invalid, it should be use of technical, organization and cultural means comprehensively to contribute a Reliability Organization.