高風險產業意味著該產業有較高的事故發生率或可能造成嚴重的後果，舉凡金屬製造、營造業、核能電廠等產業，都對人們的生命財產存在一定的風險，這些行業也一直是安全管理領域關注的要點，事故發生的原因也從檢討人為失誤，轉而檢討人為失誤背後的安全管理系統。本研究對高風險產業的安全管理進行研究，以三個個案來探討人為失誤的辨識、風險評估以及安全管理系統在實務上的應用情形。本研究透過人為因素分析與歸類系統的應用，找出在金屬製造業中所發生的意外事故各層級風險因子間的關聯性；對核能電廠在面臨嚴重意外事故時的處理程序進行人為失誤預測及可靠度評估；以及應用安全管理系統之架構對營造業於篩選承包商資格審查工具進行評估，找出理論與現實的差距。本研究的成果可從不同面向改善高風險產業的安全管理系統，以增進工作場所的安全性。

High risk industries have a higher probability of incident or higher severity of consequence. Typically, such industries include metal manufacturing, construction, and nuclear power plant, which have a risk to life and property. As such, these sectors are important to safety management researchers. The investigation of incidents no longer is limited on the human error, but also investigates the factors behind the human error, such as the safety management system. This research looked at the safety management systems of several high risk industries. Three cases selected from high risk industries were investigated to explore the issues of identification of human error, risk assessment, and safety management system in practice. First, human factor analysis and classification system was applied to investigate injury incidents in metal manufacturing. The relationships among the risk factors of the incidents were also assessed. Second, this research applied the technologies of human error prediction and human reliability analysis to evaluate the risk of a nuclear power plant for having a severe accident. Third, this research characterized prequalification tools currently used to identify the gap between practices and organizational theories. The results of this research can be applied to improve the safety management system of high risk industries from several perspectives and to enhance workplace safety.

致謝 I
摘要 III
ABSTRACT IV
目錄 V
表目錄 VIII
圖目錄 X
詞彙表 XI
第一章 緒論 1
1.1 研究背景及動機 1
1.2 研究目的 2
第二章 文獻探討 5
2.1 人為失誤 5
2.1.1 人為失誤分類 5
2.1.2 人為失誤預測 9
2.2 安全管理 14
第三章 鋼鐵業人為失誤分析 19
3.1 背景 19
3.2 研究方法 20
3.2.1 資料來源 20
3.2.2 資料編碼 21
3.2.3 編碼實例 23
3.2.4 統計分析 24
3.3 結果 24
3.3.1 直接原因統計 24
3.3.2 HFACS風險因子統計 25
3.3.3 HFACS風險因子間關聯性分析 30
3.4 討論 32
3.4.1 造成鋼鐵業工安事故的風險因子 32
3.4.2 風險因子間的關聯性 36
3.5 小結 39
第四章 核能發電廠人為失誤預測 40
4.1 背景 40
4.2 研究方法 44
4.2.1 建立嚴重事故事處理事件樹 44
4.2.2 以SPAR-H進行人為失誤預測 47
4.3 結果 48
4.3.1 福島事件條件回溯 48
4.3.2 URG執行人為可靠度計算 51
4.4 討論 58
4.5 小結 60
第五章 安全管理系統在建築業承包商選擇的應用與缺漏 62
5.1 背景 62
5.2 研究方法 64
5.2.1 資格審查工具搜尋及篩選 64
5.2.2 資格審查工具問項匯整 64
5.3 結果 65
5.3.1 資格審查工具使用者類型 65
5.3.2 資格審查工具的問項與歸類 66
5.3.3 比較各類型使用者的資格審查工具 69
5.4 討論 71
5.4.1 資格審查工具常使用的領先指標 71
5.4.2 失衡的SMS審查 72
5.5 小結 73
第六章 綜合討論與結論 75
6.1 研究貢獻 75
6.2 不同產業之共通問題 76
6.3 研究限制與未來研究方向 78
參考文獻 80
附錄 86
附錄A HFACS十九項風險因子之細項描述 86
附錄B 不同決策者及水源狀態之事件樹分析結果 89
附錄C 資格審查工具安全問項彙整(K.-H. LIU ET AL., 2019) 95

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