|本期目录/Table of Contents|

[1]吕千,傅贵.事故调查报告中事故原因分析的改进*——基于企业事故案例学习视角[J].中国安全生产科学技术,2021,17(10):172-178.[doi:10.11731/j.issn.1673-193x.2021.10.026]
 LYU Qian,FU Gui.Improvement of cause analysis in accident investigation reports——A perspective of enterprise accident cases learning[J].JOURNAL OF SAFETY SCIENCE AND TECHNOLOGY,2021,17(10):172-178.[doi:10.11731/j.issn.1673-193x.2021.10.026]
点击复制

事故调查报告中事故原因分析的改进*——基于企业事故案例学习视角
分享到:

《中国安全生产科学技术》[ISSN:1673-193X/CN:11-5335/TB]

卷:
17
期数:
2021年10期
页码:
172-178
栏目:
职业安全卫生管理与技术
出版日期:
2021-10-31

文章信息/Info

Title:
Improvement of cause analysis in accident investigation reports——A perspective of enterprise accident cases learning
文章编号:
1673-193X(2021)-10-0172-07
作者:
吕千傅贵
(中国矿业大学(北京) 应急管理与安全工程学院,北京 100083)
Author(s):
LYU Qian FU Gui
(School of Emergency Management and Safety Engineering,China University of Mining & Technology-Beijing,Beijing 100083,China)
关键词:
事故调查报告原因分析案例学习改进建议事故致因理论
Keywords:
accident investigation report cause analysis cases learning improvement suggestion accident causation theory
分类号:
X928
DOI:
10.11731/j.issn.1673-193x.2021.10.026
文献标志码:
A
摘要:
为进一步提高我国事故调查报告的质量,更好地满足企业对事故案例学习的需要,通过案例分析事故调查报告中事故原因部分存在的问题及其原因,并在此基础上提出采用事故致因理论来改进事故调查报告的思路;应用24Model改进天嘉宜化工有限公司“3·21”特别重大爆炸事故的事故原因分析,以此来验证本文思路的可行性和有效性。研究结果表明,使用事故致因理论能够更加科学地归纳事故原因,增强措施的针对性和可操作性,可有效改善事故调查报告的质量。
Abstract:
In order to improve the quality of accident investigation reports in China and better meet the needs of accident cases learning and training in the enterprises,the problems and their causes of accident cause part in the accident investigation reports were analyzed by case study.On this basis,an idea of using the accident causation theory to improve the accident investigation reports was put forward.The 24Model was applied to improve the cause analysis of the “3·21” extraordinarily serious explosion accident of Tianjiayi chemical company to verify the feasibility and effectiveness of the new idea.The results showed that the accident causation theory could be used to scientifically summarize the accident causes,enhance the pertinence and operability of measures,and effectively improve the quality of accident investigation reports.

参考文献/References:

[1]DRUPSTEEN L,GULDENMUND F.What is learning?A review of the safety literature to define learning from incidents,accidents and disasters[J].Journal of Contingencies and Crisis Management,2014,22(2):81-96.
[2]STEMN E,BOFINGER C,CLIFF D,et al.Failure to learn from safety incidents:status,challenges and opportunities[J].Safety Science,2018,101:313-325.
[3]马奔,程海漫.危机学习的困境:基于特别重大事故调查报告的分析[J].公共行政评论,2017,10(2):118-139. MA Ben,CHENG Haiman.The dilemma of learning from crisis:an analysis based on extraordinarily serious accident investigation reports[J].Journal of Public Administration,2017,10(2):118-139.
[4]张美莲.危机学习面临的挑战——一个事故调查报告的视角[J].吉首大学学报(社会科学版),2016,37(1):91-99. ZHANG Meilian.Challenges of crisis learning in China——A perspective of after action reports[J].Journal of Jishou University(Social Sciences),2016,37(1):91-99.
[5]宋守信,许葭,陈明利,等.交通事故报告撰写改进设想[J].劳动保护,2019(4):54-57.
[6]SALGUERO-CAPARROS F,SUREZ-CEBADOR M,RUBIO-ROMERO J C.Analysis of investigation reports on occupational accidents[J].Safety Science,2015,72:329-336.
[7]CEDERGREN A,PETERSEN K.Prerequisites for learning from accident investigations - a cross-country comparison of national accident investigation boards[J].Safety Science,2011,49(8-9):1238-1245.
[8]BENNER L.Accident investigation data:users’ unrecognized challenges[J].Safety Science,2019,118:309-315.
[9]FARAZMAND A.Learning from the Katrina crisis:a global and international perspective with implications for future crisis management[J].Public Administration Review,2007,67(s1):149-159.
[10]WAHLSTRM B.Organisational learning - reflections from the nuclear industry[J].Safety Science,2011,49(1):65-74.
[11]傅贵.安全科学学及其应用探讨[J].安全,2019,40(2):1-10. FU Gui.The science of safety science and its practical implications[J].Safety & Security,2019,40(2):1-10.
[12]傅贵,郭孝臣.事故致因理论的研究与应用简评[J].安全,2019,40(9):1-5. FU Gui,GUO Xiaochen.A brief review on the study and application of accident causation theory[J].Safety & Security,2019,40(9):1-5.
[13]傅贵,索晓,贾清淞,等.10种事故致因模型的对比研究[J].中国安全生产科学技术,2018,14(2):58-63. FU Gui,SUO Xiao,JIA Qingsong,et al.Comparative study on ten accident causation models[J].Journal of Safety Science and Technology,2018,14(2):58-63.
[14]罗春红,谢贤平.事故致因理论的比较分析[J].中国安全生产科学技术,2007,3(5):111-115. LUO Chunhong,XIE Xianping.Comparison study of accident-causing theories[J].Journal of Safety Science and Technology,2007,3(5):111-115.
[15]祝楷.基于系统论的STAMP模型在煤矿事故分析中的应用[J].系统工程理论与实践,2018,38(4):1069-1081. ZHU Kai.Application of STAMP model in coal mine accident analysis[J].Systems Engineering-Theory & Practice,2018,38(4):1069-1081.
[16]FU G,XIE X,JIA Q,et al.The development history of accident causation models in the past 100 years:24Model,a more modern accident causation model[J].Process Safety and Environmental Protection,2020,134:47-82.
[17]樊运晓,卢明,李智,等.基于危险属性的事故致因理论综述[J].中国安全科学学报,2014,24(11):139-145. FAN Yunxiao,LU Ming,LI Zhi,et al.A review of accident modelling approaches based on components of hazards[J].China Safety Science Journal,2014,24(11):139-145.
[18]LEVESON N.A new accident model for engineering safer systems[J].Safety Science,2004,42(4):237-270.
[19]HOLLNAGEL E.FRAM:the functional resonance analysis method,modelling complex socio-technical systems [M].Surrey:Ashgate Publishing Limited,2012:45-46.
[20]傅贵,殷文韬,董继业,等.行为安全“2-4”模型及其在煤矿安全管理中的应用[J].煤炭学报,2013,38(7):1123-1129. FU Gui,YIN Wentao,DONG Jiye,et al.Behavior-based accident causation:the “2-4” model and its safety implications in coal mines[J].Journal of China Coal Society,2013,38(7):1123-1129.
[21]傅贵,陆柏,陈秀珍.基于行为科学的组织安全管理方案模型[J].中国安全科学学报,2005(9):21-27. FU Gui,LU Bai,CHEN Xiuzhen.Behavior based model for organizational safety management[J].China Safety Science Journal,2005(9):21-27.
[22]傅贵.安全学科结构的研究[M].墨尔本:安全科学出版社,2015:29-34.
[23]傅贵,樊运晓,佟瑞鹏,等.通用事故原因分析方法(第4版)[J].事故预防学报,2016,2(1):7-12. FU Gui,FAN Yunxiao,TONG Ruipeng,et al.A universal methodology for the causation analysis of accidents (4th Edition) [J].Journal of Accident Prevention,2016,2(1):7-12.
[24]傅贵,索晓,王春雪.24Model的系统特性研究[J].系统工程理论与实践,2018,38(1):263-272. FU Gui,SUO Xiao,WANG Chunxue.Study on the systematic characteristics of 24Model[J].Systems Engineering-Theory & Practice,2018,38(1):263-272.
[25]付净,聂方超,荆德吉,等.数据挖掘在预测组织事故防控效果中的应用[J].中国安全生产科学技术,2020,16(10):152-157. FU Jing,NIE Fangchao,JING Deji,et al.Application of data mining in predicting prevention and control effect of organizational accidents[J].Journal of Safety Science and Technology,2020,16(10):152-157.

相似文献/References:

[1]朱琳,刘素霞,张赞赞.影响农民工职业安全健康需求的自身因素分析[J].中国安全生产科学技术,2011,7(4):80.
 ZHU Lin,LIU Su-xia,ZHANG Zan-zan.The self-factors analysis of migrant workers’ occupational safety requirement[J].JOURNAL OF SAFETY SCIENCE AND TECHNOLOGY,2011,7(10):80.
[2]杨小玉.隧道二次衬砌与初期支护间脱空原因分析及处理[J].中国安全生产科学技术,2012,8(2):140.
 YANG Xiao yu.Cause analysis and treatment scheme of the separation between the secondary liner and primary support of tunnel[J].JOURNAL OF SAFETY SCIENCE AND TECHNOLOGY,2012,8(10):140.
[3]杨乃莲.2007-2011年我国烟花爆竹事故统计分析研究[J].中国安全生产科学技术,2013,9(5):72.[doi:10.11731/j.issn.1673-193x.2013.05.014]
 YANG Nai lian.Statistical analysis on firework accidents occurring in China during 2007-2011[J].JOURNAL OF SAFETY SCIENCE AND TECHNOLOGY,2013,9(10):72.[doi:10.11731/j.issn.1673-193x.2013.05.014]
[4]李莎莎,崔铁军.系统故障演化过程不连续现象的原因及消除方法研究*[J].中国安全生产科学技术,2022,18(9):49.[doi:10.11731/j.issn.1673-193x.2022.09.007]
 LI Shasha,CUI Tiejun.Research on causes and elimination methods of discontinuity phenomenon in system fault evolution process[J].JOURNAL OF SAFETY SCIENCE AND TECHNOLOGY,2022,18(10):49.[doi:10.11731/j.issn.1673-193x.2022.09.007]

备注/Memo

备注/Memo:
收稿日期: 2021-06-07
* 基金项目: 国家自然科学基金项目(51534008);中国矿业大学(北京)本科教育教学改革与研究重点项目(J20ZD03);中央高校基本科研业务费专项资金资助项目(2021YJSAQ26)
作者简介: 吕千,博士研究生,主要研究方向为事故原因分析,行为安全。
更新日期/Last Update: 2021-11-03