工安意外是台灣勞工致死率高的原因之一，降低工安意外的發生一直是學者以及管理階層努力的目標。近年來工安意外頻傳，相關人員往往在事發後才相互檢討責任歸屬，然而在指標性嚴重的事件發生後，類似的案件極可能再度發生。此類情況可能的原因是工安人員未確實檢測潛在的意外風險因子，意即大多數工安的工安調查僅能發現表層的肇因，或是大多歸因於操作者本身的不注意。許多研究指出，工安意外的發生絕不只是檢討操作者個人的作業流程，一個意外的發生通常是與數個環繞事件的風險因子如操作者、技術環境、監督者與高層決策者有關。對於隱性的潛在風險因子，目前最有效益的分析為人為因素分析與歸類系統(HFACS)，然而此分析工具的使用者大多侷限於了解理論的人因專家學者們，而學者依照掌握之資料做事後分析時可能因為資訊不足而產生偏差。最適合做工安意外分析的應是第一線的作業人員，因此本研究希望能夠消弭產學之間的隔閡，藉由輔助系統快速引導工安人員應用HFACS在第一線對於工安意外發生的原因進行深入分析。參與者選擇的答案將與研究人員的建議參考選項做比較而得出得分。數據分析將使用變異數分析與組內相關係數分析數據之內部一致性，進而探討兩種不同輔助介面對於使用者的輔助績效。研究結果彙整所得的資料亦將可提供國內產業界提升工業安全的建議方向與使用HFACS架構分析工安意外的參考建議。本研究結果可普及人為因素分析與歸類系統可行性，提供台灣工業產業新型態的工安意外分析方式並有效探究工安意外隱性之潛在風險因子，進而提升工業安全。

Industrial accident is one of the major reason leading to workplace fatalities in Taiwan, and reducing the occurrence of industrial accidents has always been the objective for researchers and upper level management. The frequency of industrial accidents has risen for recent decades, and related personnel would usually examine the duties and responsibilities only after the accidents. However, this might potentially lead to the re-occurrence of the similar accidents. Such scenario is likely resulted from the ignorance that the safety rated personnel do not consider the latent risky factors; that is to say, most of the later investigations of industrial accidents merely reveal the explicit forms of causation or contribute the accidents to the inattention of workers. Several researches have suggested that the reviews of industrial accidents should focus on not only the operating procedures of workers but some other risk factors such as technical environment, supervisors and upper level management. Presently, one of the most effective tool to address the latent risky factors is the Human Factor Analysis and Classification System (HFACS). However, the usage of this analytical tool is usually limited to only the experts familiar with relevant theories, and in some real case with insufficient information in hand, experts might mishandle the situations and give out wrong evaluation. Generally speaking, frontline workers are the best candidates to perform this analysis, so the purpose of this paper was to reduce the barriers between industry and academia by introducing the handy system for safety related personnel to analyze the causes of accidents based on the principles of HFACS. The options chosen by the participants were compared to the reference provided by the researchers, and the resulting credits were marked. Analysis of variance and reliability examination were used in data analysis.
The corresponding effectiveness of the two assistant interfaces was also evaluated. The results of this research can facilitate the usability of HFACS and therefore offer a revolutionary type of analysis methods to examine the latent risky factors in accidents, leading to enhancement of industrial safety.

第一章 緒論 8
1.1　研究背景與動機 8
1.2 研究目的 9
1.3 研究範圍與限制 11
1.4 研究流程 12
第二章 文獻回顧 14
2.1 工安意外探討分析 14
2.1.1 骨牌理論 15
2.1.2 多重因果理論 15
2.2　人為因素失誤模型 16
2.2.1 SHELL 模型 16
2.2.2 起司模型 16
2.2.3 人為因素分析與歸類系統 17
第三章 研究方法 25
3.1　研究架構與假說 26
3.2　研究流程 27
3.2.1　介面開發 27
3.2.2　研究參與者 32
3.2.3　實驗流程 32
3.3　資料整理與分析 35
第四章 結果 38
4.1　兩版本輔助系統分析之結果比較 38
4.1.1　正確率差異 38
4.1.2　時間差異 41
4.1.3　主觀負荷程度差異 42
4.1.4　一致性分析 44
4.2　研究假設驗證 45
第五章　討論 46
5.1　兩版本輔助系統之分析比較 46
5.2　基於HFACS架構對於4案例之分析 51
5.2.1　案例一 51
5.2.2　案例二 54
5.2.3　案例三 57
5.2.4　案例四 60
5.2.5　小結 63
5.3　研究限制 66
第六章　結論與建議 67
6.1　研究結論與貢獻 67
6.2　後續研究方向 68
誌謝 68
參考文獻 69
附錄一、HFACS風險因子之定義 (輔助系統Type II) 72
附錄二、HFACS系統的說明文檔 78
附錄三、NASA-TLX主觀負荷量表 80
附錄四、工安意外案例練習題1 (自屋頂洞墜落) 81
附錄五、工安意外案例練習題2 (非該工地人員而從高樓墜落而死) 84
附錄六、工安意外正式分析案例1 (冷卻攪拌機清潔作業) 86
附錄七、工安意外正式分析案例2 (夾捲致死意外) 89
附錄八、工安意外正式分析案例3 (鋼筋倒塌壓傷頭部致死) 92
附錄九、工安意外正式分析案例4 (如廁氨氣中毒) 94
附錄十、基於HFACS架構進行事故分析的參考建議 97

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