| Summary: | 碩士 === 國立交通大學 === 經營管理研究所 === 87 === 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.
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