基于事故机理和管理因素的地铁坍塌事故分析——以杭州地铁坍塌事故为实证

从技术角度分析地铁坍塌事故发生的机理,以安全事故致因层次为基础,将管理因素分为4部分,即人员因素、环境因素、材料因素和设备因素;进一步分析地铁坍塌事故发生的原因,构建地铁坍塌事故致因的鱼刺图;实证分析杭州地铁坍塌事故的致因,并构建杭州地铁坍塌事故致因的鱼刺图;在实证分析基础上,从地铁施工前与地铁施工时两时间段,针对人员因素、环境因素、材料因素和设备因素4方面管理因素,提出地铁坍塌事故的防范措施。以事故机理研究为基础,以管理因素研究为核心是研究地铁坍塌事故的必由之路,将对地铁工程的安全管理有一定的指导意义。     

内-外因事故致因理论与实现安全生产的途径

采用辩证的方法对事故发生的机理进行研究,提出了内-外因事故致因理论,阐明危险源是导致事故的内因,人—物—环—管中的不安全因素是导致事故的外因。根据危险源的存在形式,指出了有效控制危险源的基本手段和措施。通过深入分析人—物—环—管中的不安全因素的产生及导致的后果,从技术和管理方面论述了防止事故发生应采取的措施。最后提出将本质安全化与风险预控管理相结合,是实现安全生产的根本途径。内-外因事故致因理论为企业安全管理提供了理论,具有实用价值和参考意义。     

事故致因理论的研究与应用简评

阐明事故致因理论的重要性和应用情况对于促进其发展、应用及提高事故预防效果十分重要。通过分析国内外的重要观点得知,安全科学是事故预防的科学,事故致因理论是发现事故原因、有效预防事故的工具,当然具有特别的重要性;但事故致因理论研究在我国开展较晚,所以目前的研究与应用并不充分。综合以往文献,给出了事故致因理论的实质性科学含义是事故的原因定义、原因间、原因与事故间的逻辑关系,它们可形象地综合表达为事故致因模型,其获取过程中不可或缺的方法是对以往事故案例的原因分析;通过观察安全管理实务认识到,社会组织要有效管理其安全健康和环保业务,选择一种事故致因模型作为总体思路且连续运转,十分必要。     

浅埋公路隧道施工塌方事故的预防与整治技术研究

塌方事故经常发生在浅埋隧道施工过程中,这就成为造成工期延误和生命财产损失的一个重要安全隐患。随着我国公路工程建设的的迅速发展,公路隧道的建设规模越来越大,隧道施工过程中围岩稳定性问题也更加突出。笔者根据深圳盐田到坝岗高速公路段大梅沙隧道开挖的工程实例,对隧道塌方的原因进行了深入研究,结合实际与理论分析,取得了一些成果:得出隧道仰拱封闭距离的合理范围;将塌方类型分为未塌穿型和塌穿型两类,分别探讨了它们的治理与防治技术措施,并提出可行的处理比选方案;研究了管棚支护在防治塌方中的重要作用,就其力学效应分为梁拱效应、环槽效应、强化岩体效应3个方面加以阐释;最后提出了综合超前处置的重要思路和途径。     

基于DEMATEL/ISM的深水井喷风险影响因素研究*

为提高深水井喷事故风险管理水平，提出研究深水井喷风险影响因素的分析方法。从技术、人员、环境和管理4个方面，识别深水井喷事故风险致因因素，建立深水井喷事故风险评价指标体系；运用矩阵决策实验室分析法（DEMATEL），研究风险因素之间的相互影响关系，计算不同风险因素的中心度和原因度，确定关键风险因素；进一步基于解释结构模型（ISM）划分不同影响因素的层次结构，分析风险因素之间的综合影响关系，建立深水井喷事故风险影响因素模型。结果表明:层级1为近邻致因，可直接导致井喷事故的发生；层级2~7为过渡致因，在风险传递过程中起到桥梁作用，对井喷事故的直接影响较小；而层级8则为本质致因，重视本质致因的改善有利于从根源上降低井喷事故的风险。研究结果可为深水井喷事故风险的预防和控制提供理论依据。     

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.     

水电工程高危作业风险影响因素的SEM模型

为探索水电工程高危作业的事故致因机理,耦联分析水电工程施工风险管理过程,从"施工企业影响"、"施工安全管理"、"施工人员行为"、"现场作业相关因素"等方面归纳总结水电工程施工事故风险要素及构成体系;在此基础上,通过问卷调查收集基础数据并定义研究变量属性,抽象风险与影响因素关系的概念模型,建立与检验高危作业风险的SEM模型;然后,以修正指数MI为判据,修正和优化SEM模型。研究结果表明:安全管理制度、教育培训、职业健康环境、个人决策能力对水电高危作业风险具有显著影响,是风险监管的重点,同时也启示风险管理者应深入贯彻"以人为本"的理念,加强"顶层制度设计"。     

事故致因“2-4”模型及其事故原因因素编码研究

事故致因模型是用于事故原因分析和预防的重要理论依据,模型的可操作性是决定事故预防效果的重要影响因素。对目前国内研究较为持续和系统的事故致因"2-4"模型进行了深入研究,以增强其在事故分析时的可操作性。首先,研究了事故致因"2-4"模型中组织内、外部原因的各个阶段原因因素的划分情况;其次,根据得到的各阶段原因因素划分结果,对应用事故致因"2-4"模型分析事故原因的因素进行了编码;最后,以一起重大瓦斯爆炸事故为例,对事故致因"2-4"模型原因因素编码系统的有效性进行了实证研究。划分了事故致因"2-4"模型中的各原因模块中的原因因素,并得到了不安全动作和物态、习惯性不安全行为、安全管理体系、安全文化、外部因素等5个层级原因,确定了基于事故致因"2-4"模型的30个原因因素。对事故原因因素进行系统编码,提高了应用事故致因"2-4"模型进行事故原因分析和事故预防的可操作性,增强了其应用实践性。     

Identifying management practices that drive production-line workers’ engagement through qualitative analysis

Introduction: Engagement research - most often defined by a worker’s psychological state of vigor, dedication, and absorption - pays little attention to production-line workers. This study therefore explores factors that drive workers’ engagement with health and safety (H&S) in a production-line context as well as their perception of managerial influence Furthermore, the study adds to the body of research by exploring H&S engagement concepts through the use of qualitative research methods. Method: 38 semi-structured interviews were conducted and analyzed through template analysis to identify themes that promote and hinder engagement. Results: The main engagement drivers were found to be: (a) the displayed safety focus of the company in organizational and social aspects; (b) the quality of the communication approach with respect to quality, consistency and direction; and (c) the environment encompassing the relationship between workers and supervisors and peers as well as the psychological environment. Notably, a trusting relationship between supervisors and workers appeared to be the most influential driver in determining engaged H&S behavior. Discussion and impact in industry: The study highlights factors that could be adapted to improve engagement and consequently enhance H&S approaches. Originality: The study reported in this paper offers a unique insight into individual production workers’ perceived drivers of H&S engagement using Qualitative Analysis. Practical applications: The study identified the important role that supervisors play in workers’ H&S engagement levels and what skills they need to employ to enhance workers’ engagement in general and in the context of H&S behavior and performance. Furthermore, the importance of psychological and sociological factors in safety approaches are highlighted and were found to be key for creating safer workplaces.     

基于FDA模型的地铁列车洪淹事故致因分析*

为了从安全信息视角探究地铁列车洪淹事故原因,基于FDA（Forecast-Decision-Action）事故致因模型和真实事故案例,构建由个体（地铁行车人员）、自组织（地铁运营企业）和他组织（应急主管部门）3个事故致因子模型组成的地铁列车洪淹事故FDA致因模型,并针对安全管理重要环节提出事故预防建议。研究结果表明:阻断事故致因主链或子链、保证必要安全信息充分且完备、防范安全欺骗行为,可有效预防地铁列车洪淹事故,通过实证案例分析验证FDA模型可显著提升地铁防洪应急管理水平。     

事故致因因素和危险源理论分析

基于事故的致因因素,国内外提出了各种危险源的概念和分类方式,如能量单元的危险源、两类危险源和三类危险源。我国安全生产法规和标准对事故致因因素也有"危险因素"、"有害因素"、"不安全因素"、"事故隐患"等术语形式的表述。为准确理解和运用系统安全理论和方法,应基于事故致因理论,系统分析事故致因因素,在该基础上,诠释各种危险源理论,明晰各种涉及事故致因因素的概念。分析表明:事故致因因素包括能量物质或载体、物的不安全状态和人的不安全行为以及管理因素;各种危险源的概念和分类,都是基于事故致因因素的划分和表述。     

传统中医学理论与企业安全生产风险管理

笔者将传统中医学理论与企业安全生产风险管理相结合,在事故致因、事故预防、安全管理等方面,借鉴中医的预防思想、整体观念、五行学说、辨证施治等理论方法,分析研究指出:企业发生安全事故如同人体得病,正气不足是发病的内在根据,邪气入侵是发病的重要条件。因此,发生事故的根本原因在于企业本身;要从研究企业自身的影响安全生产诸要素之间的相互滋生和相互制约的关系入手,加强事故预防工作,坚持整体性的原则,辨证分析事故原因,加大企业生产安全的精神和物质保障,才能全面提高企业的生产安全风险管理水平。     

公路工程施工安全事故致因模型构建

为了探究公路施工安全事故诱因及其影响关系,基于"4M"理论和事故致因"2-4"模型,识别公路工程施工安全事故致因因素并确定模型框架,运用SPSS Modeler软件对2007~2017年426起事故进行关联规则挖掘,采取路径分析与重要度分析,构建出公路工程施工安全事故致因模型。结果表明:施工单位内外部原因共同引发公路工程施工安全事故,外部原因来源于建设单位、监理单位和勘察设计单位的安全管理缺失,而施工单位内部影响因素中,人的不安全动作、物的不安全因素、不良的生产环境和自然环境是事故发生的直接原因,无效的安全监管和作业层安全素质及能力不强是间接原因,根本原因是施工程序和技术方案存在缺陷,根源原因是决策层和管理层的安全素质及能力有待提高。该模型系统展现了工程施工项目安全事故致因因素的影响关系和重要程度,为公路工程施工安全事故预防提供指导。     

核电厂人因事故预防的定量化决策

人因事故的分析与预防是核电厂安全运行和管理的重要内容。笔者提出的系统安全性层次分析法主要从两种角度考虑系统的安全性:专家能力权值和安全性矩阵的建立。采用专家判断矩阵确定事故原因对系统安全性的重要度排序。举例某核电厂事故定量分析进行说明,在对事故进行原因分析基础上,构建事故影响因素层次模型,利用层次分析法分析得出事故原因重要度排序由高到低依次为组织管理、操作人员、人机界面、培训与设备状态,并据此提出了相应的预防与改进措施,为安全性要求较高的复杂工业系统提供事故预防的定量化决策依据。     

Workplace and organisational factors in accident analysis within the Food Industry

This paper focuses on the causes of accidents at work in the Food Industry Sector and it covers both immediate and systemic causation factors, using data collected in Portugal. In the first part, accident data is analysed by looking at harmonised variables within the Eurostat recording system, allowing a portrait of the accidents occurred and their immediate causes. To complement the study, a second part was designed to deepen the insight into underlying factors, as well as the relevant organisational conditions; this complementary part comprised an in-depth analysis of 30 accidents, carried out in the field by visiting several enterprises of the sector and conducting interviews with the injured people and their managers. For eliciting and analysing this information, the WAIT method was applied together with its classification schemes. The results are presented and discussed, showing the usefulness of certain new Eurostat variables, such as the deviation and the contact. However, they also demonstrate that the current variables are not yet sufficient to clarify accident mechanisms on which to build up knowledge and develop better prevention strategies. The authors argue for the need of more detailed information and propose an additional variable, associated with the deviation, aimed at promoting the inclusion of specific underlying factors within the local workplace environment.     

An urban pipeline accident model based on system engineering and game theory

Urban pipeline accidents are caused by complex social-technical factors, in which urban communities and pipeline systems are involved. Such accidents can thus be investigated from the viewpoint of system engineering. System-Theoretic Accident Model and Processes (STAMP) is a systemic method for safety assessment, which has been adopted in many domains. This approach can provide deep insights of accident causes by considering direct and indirect factors. Meanwhile, competition and cooperation between stakeholders in accidents are observed. Therefore, these parties can also be analyzed with the game theory. That is, stakeholders in STAMP can be regarded as players in game. The aim of this paper is to provide a new insight to analyze urban pipeline accidents by considering both STAMP and game theory. In this paper, we proposed an accident model for urban pipelines, with a case study of China-Qingdao pipeline accident occurred in 2013. We concluded that accident reasons can be investigated in-depth and lessons can be learned from analyzing causal factors by using STAMP. Based on results generated from STAMP, we applied the game theory to analyze roles that government and companies act in the China-Qingdao urban pipeline accident. The results show that current punishment and incentive systems are incomplete, lacking of the driving force and constraining force for the stakeholders involved in the accident.     

Occupational injury and accident research: A comprehensive review

In this paper, a comprehensive review of the concepts of occupational injury and accident causation and prevention is presented. Starting with hazard identification, the issues on risk assessment, accident causation, and intervention strategies are discussed progressively. The distinctiveness and overlaps in accident and injury research are highlighted. Both empirical research in terms of hypotheses tested and theoretical research such as accident causation models are compared and contrasted. Finally, based on the critical appraisal of the comprehensive review, future research directions on occupational injury research are delineated.     

古典、现代事故致因链在我国煤矿事故分析中的比较研究

事故致因理论是事故的发生机理和理论模型,事故致因链是其核心,是导致事故发生的基本路线。通过对古典事故致因链的代表:海因里希因果连锁理论及现代事故致因链的代表:行为安全"2-4"模型的原因定义、组织概念的引入、链条逻辑关系、事故预防策略等多方面的比较,并应用于一起真实煤矿事故案例分析,发现行为安全"2-4"模型不仅继承和发展了因果连锁理论的优点,更是改进其缺点,在对我国煤矿事故案例分析中更加有效,且在各层级均可找到事故预防的策略。     

Towards an evaluation of accident investigation methods in terms of their alignment with accident causation models

The purpose of this paper is to reflect on accident causation models and accident investigation methods. Theories on accident causation and the modelling of accident mechanisms, as well as a number of methods for accident investigation have been developed and described in the literature. The evolution of accident causation models over time shows a shift from the sequence of events to the representation of the whole system. Respectively, the evolution of accident investigation methods over time reveals a gradual shift from searching for a single immediate cause, to the recognition of multiple causes. In order to evaluate the accident investigation methods, specific plausible requirements were established in order to verify that a specific accident investigation method fulfils the principles of a specific accident causation model or give evidence to the degree of alignment between them. Since different models approach accident causation in different ways, methods linked to these models provide fragmentary information regarding the accident. It is therefore expected that using a combination of model-method pairs could provide a more reliable platform for accident analysis.