对建立第三方事故调查机制的探讨

事故调查的根本目的在于查找事故的可能原因并提出事故的预防措施,而事故调查的独立性对此根本目的起关键作用。我国安全生产管理体制建设起步较晚,事故管理机制发展不成熟,与国外先进事故调查理念相比,我国事故调查机制缺乏独立性的保障,主要表现在技术调查与司法调查未能分离、事故调查报告未能完全公开、事故调查的客观性保障不足,限制了我国事故调查水平的进一步提高。通过分析国外第三方事故调查的机制的优势并结合我国国情,从第三方事故调查的任务、人员编制、人员培训、责任与权利、法律义务等方面提出我国第三方事故调查机制的框架,并规划了构建第三方事故调查的三阶段进程及其主要内容,以逐步实现第三方事故调查的公正、客观、高效,更好地促进我国安全生产管理水平的提高。     

国内外水上交通事故调查机制对比分析研究

事故调查的根本目的是为了查清事故原因、避免同类事故的反复发生。为进一步完善我国水上交通事故调查体制机制,避免和减少水上交通事故发生,在总结凝练美国、英国、德国、日本等国外部分发达国家水上交通事故调查研究信息资料的基础上,从水上交通事故调查的法律依据、调查目的、调查机构及职能、调查队伍、调查流程等方面,对比分析了我国与国外部分发达国家水上交通事故调查体制机制的区别。针对目前我国水上交通事故调查工作存在的突出问题和不足,从完善事故调查机构与职能、提高调查人员准入条件、原因调查与责任追究分离、公开调查过程等方面,提出了完善和改进我国水上交通事故调查体制机制的具体措施建议。     

中欧事故报告与调查处理比较研究

事故调查是安全生产工作中的重要环节,是对生产安全事故及时处理、发现问题的重要手段,其目的在于找出导致事故发生的可能原因,进而提出防止类似事故再次发生的对策措施。从法律依据、事故分级、事故调查程序、事故调查主体、调查组组成、事故调查期限、责任追究、事故调查经费来源、信息公开等方面开展了我国与欧盟的事故报告与事故调查处理对比分析,剖析了我国目前事故报告与调查处理的工作存在的一些问题,研究和借鉴了欧盟的一些先进理念和做法,并提出改进我国事故报告与调查处理的若干对策建议。     

我国安全生产事故调查分级培训机制研究

调查培训对于调查人员素质、技能和知识水平的提高具有十分重要的作用。本文首先对比分析了发达国家事故调查员培训的理念、方法和机制，结合我国伤亡事故分级调查处理的原则，引入分级培训机制，通过分析不同层次及类型的事故调查中调查员应具备的知识和技能，设计适应实际需求的培训机制和方法，建立事故调查培训绩效评估体系，并提出建立健全事故调查培训体制对策，有利于集中和充分利用社会资源，提高调查人员整体素质。通过改进事故调查培训机制，有利于提高事故调查的科学性和权威性，使人们能真正从事故中吸取教训和总结经验，防止类似事故的再次发生。     

环评机构从经济独立到评价独立方法研究

针对环评机构在市场化中丧失评价独立性,严重损害环境影响评价制度有效性的问题。提出通过创新评价费用定价方式、招标委托方式、支付方式及限制环评机构数量等途径保障环评机构经济独立性。通过增加环评透明度、责任追究与淘汰制度、建立评价机构分级制度督促取得了经济独立性的环评机构保持其评价独立性,真正实现环评机构独立、科学、客观、公正地开展环评工作,提高环境影响评价质量。     

协和客机坠毁事故调查始未

事故调查是通过收集事故发生后所表现出来的各种现象、信息、痕迹与特征，并加以分析、鉴别与判断，从而揭示引起事故的原因。因此，事故调查是一个从果求因的逆向思维过程。在这种逆向认识客观事物的过程中，正确的思路与思维方法显得特别重要。以严谨的态度去收集、核实、分析与鉴定事故发生后所呈现出来的各种纷繁的现象、信息和面目全非的残骸，查找出事故的可能原因，通过科学的分析，逐一排除，最终认定引起事故的原因，这是国外事故调查工作的程序。客观、公正、实事求是，是调查人员应当遵循的准则。查找事故的可能原因，广泛吸取事故教训，切实改进安全工作，有效预防未来事故，才是事故调查最根本的目的。从本期开始，我们将陆续编辑一些国外重大事故调查案例。研究和借鉴其思想理论和实践经验，或许能够对我国事故调查工作的开展起到促进作用。     

建议建讧事故调查公告制度

我国的《生产安全事故报告和调查处理条例》（国务院令第493号）第34条规定：事故处理的情况由负责事故调查的人民政府或者其授权的有关部门、机构向社会公布，依法应当保密的除外。当前有些地方已经对事故处理情况向外面进行了公布，但也存在一些问题，一是没有将所有的非保密事故全部公布，二是对外公布途径限于内部文件或发布单位自己的门户网站上。     

从问责调查到问题调查——基于系统论和系统安全理论的思考与建议

生产安全事故调查处理是安全生产工作的一项重要内容,事故调查的政策和方法等的制度创新对完善我国安全生产工作的体制机制有很大意义。针对当前我国安全生产总体形势和事故调查处理的工作现状,采用对照评估的方法,分析了近三年来我国特大事故发生的态势和原因,总结了事故发生的基本规律和共性问题,基于系统安全的思想,认为安全是系统整体属性,系统脆弱性是导致重特大事故风险和严重损失的主要原因,不应简单把事故仅仅归咎于某些人或某件事的责任。据此,进一步分析生产安全事故调查处理的利弊得失,提出在现有基础上,进一步改革创新生产安全事故调查处理制度,应逐步实现从问责调查向问题调查的转变,并对如何修改《生产安全事故报告和调查处理条例》（国务院令第493号）提出了六条具体建议。     

我国安全评价制度发展现状调查

自我国引入安全评价制度以来，安全评价逐渐成为政府安全管理的一种重要手段。本文通过对政府安全监管机构的调查，旨在从政府的角度了解安全评价机制在我国的发展状况，分析问题，并提出对策措施。     

中国民航事故调查的客观公正探讨

为了防止同类事故重复发生、缓解社会和行业的猜忌和矛盾、提高中国在国际社会的形象和声誉,关注航空事故调查的客观公正已然迫切。从结果和过程两个方面探讨了事故调查中客观公正的内涵,分析了阻碍我国民航事故调查客观公正五个方面的影响因素,系统性提出了解决问题的途径。结果表明,从机构设置、规章建设、人员培养、工程能力、监督机制等方面加以完善,可以改进事故调查的结果客观和过程公正。     

数据挖掘与现场调查结合的电动汽车事故分析

为了解电池热失控引起的电动汽车自燃事故起因,降低事故发生率,统计梳理2020年新能源汽车起火事故概况,并基于动力电池失效机制和车辆运行数据,提出一种融合事故阶段安全参数关联分析、事故现场调查和全生命周期数据一致性分析的事故多维分析方法,采用该方法深入剖析一起电动汽车起火事故.研究结果表明:事故多维分析方法可通过探究事故...     

What-You-Look-For-Is-What-You-Find – The consequences of underlying accident models in eight accident investigation manuals

Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of what we currently know – or assume – about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. In this paper we examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, we focus on accident models and in particular the assumptions about how different factors interact to cause – or prevent – accidents, i.e., the accident “mechanisms”. Secondly, we focus on the scope in the sense of the factors (or factor domains) that are considered in the models – for instance (hu)man, technology, and organization (MTO). Thirdly, we focus on the system of investigation or the activities that together constitute an accident investigation project/process. We found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the ‘What-You-Look-For-Is-What-You-Find’ or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called ‘What-You-Find-Is-What-You-Fix’ or WYFIWYF principle.     

Accident in a French dynamite factory: An example of an organisational investigation

The 27th of March 2003, an explosion caused the death of four employees in a Nitrochimie pyrotechnic plant, at Billy Berclau, in the north of France. Following the accident, the ministry of Ecology and Sustainable Development appointed INERIS to perform an investigation. According to the terms of reference, the investigation would cover technical (origins of the explosion, extent of damages) as well as organisational issues, as defined by SEVESO II safety management system requirements. This paper has a threefold purpose. It intends first to illustrate with an empirical case the current trend in safety auditing and accident investigation, targeting organisational factors, alongside human factors. There are not so many published cases of accidents analysed with an organisational perspective. Secondly, it shows that it is possible to investigate organisational dimensions (through articulation of safety engineering, safety management and human and social sciences) within reasonable time frames and a reasonable amount of resources. By focusing on key actors and asking appropriate questions related to key dimensions, investigating organisational accidents might not necessarily imply spending much more resources than other steps such as damage assessment, chronological construction or identification of technical scenarios, although there are also some prerequisite conditions needed to achieve this. Finally this paper should be seen as a technical communication beyond the pyrotechnic industry.     

Accident investigation in the Norwegian petroleum industry - Common features and future challenges

In their regulations, the Petroleum Safety Authority Norway (PSA) states that the companies responsible for oil and gas exploration and production activities in Norway shall record and investigate accidents and serious incidents. This paper introduces a general model for the accident investigation process in the Norwegian petroleum industry, and presents some results derived from a comparative study of causal factors identified in offshore accident investigation reports from 2002 to 2006. The paper also offers a discussion of the improvement potential in the use of investigation methods. Finally, a discussion of future challenges in accident investigations is provided.     

一种基于贝叶斯网络的机务维修差错调查模型算法

提出一种基于贝叶斯网络的机务维修差错调查模型算法,根据已经建立的机务人为诱因导致事故/事故征候模型,利用贝叶斯原理编程实现了该算法。利用该算法对中国民航飞行学院2001-2011年的机务人为有引导的事故/事故征候依次进行分析并验证,得到了相应的事故诱因概率排序。该算法克服了样本空间不足,在事故发生以后能够在引入其他证据的情况下根据以前的经验概率得到新的事故诱因概率排序,为民航机务维修差错调查提供了可靠的技术支持。     

Modern accident investigation - Four major challenges

Nowadays, ‘investigation’ is a very commonly advocated approach and consequently is becoming an umbrella concept. ‘Investigation’ includes many types of approaches on different system levels. Originating from transport accidents and crime scenes, ‘investigation’ ranges from genocide, natural disasters, via discrimination, health care to crime fighting, economic fraud and ethical questions in engineering and management. In such a changing operating environment and widespread applications, accident investigation must reassess its distinctive role, purposes and operating conditions. It must clarify and communicate its specific aims and functions and performance to such an extent that it maintains its credibility, capability and quality in the eye of professionals, politicians as well as the public. Based on an assessment of the past performance of leading investigation agencies, practical experiences during major ad hoc accident investigations and changes in the operating environment, a SWOT analysis identified several issues as internal and external challenges in the future conduct of major investigations. Finally, the article proposes several priorities, challenging each stakeholder and expert in the investigation community to contribute from its own perspective to improve accident investigation theory and practices.     

Causation of Severe and Fatal Accidents in the Manufacturing Sector

The main purpose of this paper is to identify the most frequent causes of accidents in the manufacturing sector in Andalusia, Spain, to help safety practitioners in the task of prioritizing preventive actions. Official accident investigation reports are analyzed. A causation pattern is identified with the proportion of causes of each of the different possible groups of causes. We found evidence of a differential causation between slight and non-slight accidents. We have also found significant differences in accident causation depending on the mechanism of the accident. These results can be used to prioritize preventive actions to combat the most likely causes of each accident mechanism. We have also done research on the associations of certain latent causes with specific active (immediate) causes. These relationships show how organizational and safety management can contribute to the prevention of active failures.