組織學習在組織人為疏失防範上之意涵－以台電核能電廠運轉╱維護部門為例

Abstract

摘 要 台電核能電廠所發生的異常事件經常成為媒體報導的首要對象，累計過去幾年的事件，其中多起異常事故有重覆發生的現象。針對這些現象探究其原因，主要是既有人為疏失防範策略之存在缺失，此缺失的原因為人員作業於情境不明確時技術認知不足或不正確所導致。本研究試圖以組織學習的觀點，針對既有防範策略之缺失所造成人員有限的學習，來尋求一合理的解案。 首先透過既有防範策略特性及其缺失加以探究，並對各個防範策略關鍵要素的假設分別加以了解及分類，進而藉由組織學習所提供重覆發生解案的各種型模有效特性一一加以解析。最後，依據這些型模的特性分別針對既有人為疏失防範策略提出可行的增益成效，為組織學習在人為疏失防範上意涵之所在。 經由實例舉隅加以印證，此結果對實務上的應用可行性，並發現一個有效防範策略除了須具有綜效的特性，並存在著一個解凍－改變－結凍的機制。此種機制存在於組織學習做為人為疏失防範策略中，其目的不外是讓行動當事者及組織的心智模式維持世界觀，有效地且正確地對環境產生回應，且讓人為疏失的重覆發生事件不再出現。

ABSTRACTS The abnormal incident happened in last few years in the nuclear power plant of Taiwan power company had been major report subject of the press, accumulated incident happened in previous years, there was phenomena of reoccurrence in several cases. We discuss the cause subject to these phenomena are main defect of the existing human prevention strategy. The cause of these defect was due to the deficiency or incorrect of technical recognition of the personnel work under uncertain situation. This study subject to the limited learning resulting from deficiency of existing prevention strategy and try to seek a reasonable resolution based on the view of organization learning. First we discuss according to the characteristic of existing prevention strategy and its defect, understand and categorize respectively to the assumption of the key factors of each existing prevention strategy, and analyze the effective characteristic of each model of the resolution of reoccurrence provided by organization learning one by one, finally raise the feasible increment effect subject to all human error prevention strategy respectively according to the characteristic of these model, these are the implication of the organizational learning in prevention strategy of human error. Proving by the case example, this consequent is feasible in practice application, and found that a effective prevention strategy in addition to characteristic of synthesis, it possess mechanism of unfreezing, change, freezing as well. The purpose of the existence of these mechanism in the organization learning which serve as human error prevention strategy are no more than maintaining the weltanschauung (World View) of the mental model of the action client and the organization, response to the environment effectively and correctly, and prevent the reoccurrence of the human error.