一起网点房较大火灾事故认定与分析

对一起网点房较大火灾调查的实际案例进行分析,说明了现场勘验工作对火灾认定的重要性。根据事故调查过程,分析了此类火灾的成因及预防措施,进城务工、经商人员安全防范意识薄弱,逃生自救知识缺乏是造成火灾严重后果的重要因素。并对调查工作中的经验进行总结和介绍。     

A comparison of safety practices used by managers of high and low accident rate postal delivery offices

This study compared safety practices of managers (supervisors) of high and low accident rate postal delivery offices, particularly with respect to slip, trip and fall accidents. Identification of ‘desirable’ management safety activities was achieved using findings from previous research, manager interviews, and a focus group with Royal Mail senior safety personnel. Interviews were then conducted with 20 Delivery Office Managers (DOMs), drawn equally from matched high and low accident rate offices, to examine use of safety practices. DOMs from low accident rate offices appeared to have improved performance with respect to quality of safety communication, dealing with hazards reported on delivery walks, and accident investigation and remedial action. Efforts to reduce risks from severe weather were limited in both high and low accident offices, seemingly influenced by the organisation's emphasis on maintaining quality of service. Confusion existed regarding footwear entitlements of employees, and none of the sample of DOMs encouraged use of alternative methods of delivery to manual pouch carriage. A model is described illustrating the hierarchy of factors that may affect occurrence of slip, trip and fall accidents within a large organisation. The model indicates that supervisors' impact arises both from their attitudes and their actions. The study supports the finding of previous cross-organisational investigations that supervisors have an important influence on workplace safety.     

The development and evaluation of accident prevention routines: A case study

Information resulting from the occurrence of accidents and near-accidents is the basis for most accident prevention efforts. However, such information may not normally be incorporated into local safety activities. A group to assist supervisors in their investigations of accidents and a procedure to prompt the reporting of near-accidents by employees were tested at one company as means of improving local safety activities. The accident investigation group was in operation in all departments and was associated with improved accident reporting and prevention activities as well as a reduction in accident severity. The near-accident reporting procedure was tested in one department and led to improved knowledge about risks, although no reductions in accident frequency and severity were shown. On the basis of these results, the company safety committee decided at the end of the first year to extend the mandate of the investigation group but not to continue with near-accident reporting. Follow-ups after 2 and 3 years indicated that improvements in prevention activities had been maintained and that accident severity had been further reduced.     

A study on the impact of management system certification on safety management

This study presents an empirical investigation of the influence of management system certification on the relationship between safety management and safety performance in major accident hazard chemical industry. The perceptions of employees about six important safety management practices and self-reported safety behaviour are measured with the help of a questionnaire survey administered in eight chemical companies in the state of Kerala in India. One thousand five hundred and sixty six workers participated in the survey with a response rate of 72%. The validity and reliability of the scales are found acceptable. Analysis of the data revealed that employees in companies with OHSAS 18001, ISO 9001 and no certification at all perceive different levels of the above safety variables in them and those in OHSAS 18001 organizations are significantly higher compared with the others. Step-wise regression analysis revealed that four out of six safety management practices predicted safety behaviour in OHSAS 18001 certified organization and three safety management practices were found to predict safety behaviour in the other two groups. But, safety rules and procedures (SR) emerged as a common predictor of safety behaviour in all the three models. This study emphasizes the need for OHSAS 18001 certification to reduce the accidents and thereby to reduce liability and improve productivity and safety and health of employees.     

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。     

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.     

基于文本挖掘和复杂网络的事故致因重要度评估方法——以房屋市政较大以上事故为例

为充分挖掘事故调查报告中的有效信息,明确安全管理工作的内容.首先,利用文本挖掘分析事故调查报告,采用最小词频阈值文档频改进信息增益评估函数对分词结果降噪,通过回溯特征项在报告中的具体表述,提取事故致因,再构建同义词词库.然后,引入复杂网络以改进TF-IDF,综合事故致因因素的关联特征评估其重要度.最后,以房屋市政较大及...     

Safety climate,safety management practice and safety performance in offshore environments

Safety climate surveys were conducted on 13 offshore oil and gas installations in separate years (N=682 and 806, respectively), with nine installations common to both years. In addition, data on safety management practices were collected by questionnaire from senior management on eight installations in each year. The associations between management practices and climate scores with official accident statistics and self-reported accident involvement were tested via a series of hypotheses. Associations were found between certain safety climate scales and official accident statistics and also the proportion of respondents reporting an accident in the previous 12 months. Proficiency in some safety management practices was associated with lower official accident rates and fewer respondents reporting accidents.     

Accidents in the chemical industry: are they foreseeable?

‘Accidents recur,’ which is what Kletz [Kletz T. (1993). Lessons from disasters, how organisations have no memory and accidents recur. UK: Institution of Chemical Engineers] wrote in 1993. Indeed, despite all measures taken accidents may re-occur, but ‘disruptions’ in a process reoccur much more frequently. If a disruption occurs it may lead to an accident. If the same disruption reoccurs it is certainly suspect and should be considered as a potential precursor. In this paper, we concentrate on these disruptions and we will define them as precursors if they recur. Organizations somehow lack the ability to control such recurring disruptions that may escalate into serious accidents under certain circumstances. The presence of such precursors long before the occurrence of an accident raises doubts about how well organizations control safety.In this paper, the control mechanism inside organizations is examined, by means of several accident investigations. It will be shown that not only accidents recur, but also that disruptions recur in a period preceding the actual accident. The recurrence of these disruptions implies that the corresponding organizational control mechanism must be failing. Often, alternative circumstances prompt the escalation of such precursors and lead to actual accidents. It is demonstrated that the use of detailed accident information is of great importance for companies that are actually willing to prevent accidents through the elimination of disruptions preceding accidents.     

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。     

Major accident hazard in bioenergy production

Some recent accidents involving the bioenergy production and feedstock supply chain raised concern on the safety of such technologies. A survey of major accidents related to the production of bioenergy (intended as biomass, bioliquids/biofuels and biogas) was carried out, and a data repository was built, based on past accident reports available in the open literature and in specific databases. Data analysis shows that major accidents are increasing in recent years and their number is growing faster than bioenergy production. The results obtained represent an early warning concerning the major accident hazard of bioenergies, and suggest the importance of risk awareness and safety culture in bioenergy production, in the perspective of a safe and sustainable exploitation of renewable resources.     

Relationship of safety climate perceptions and job satisfaction among employees in the construction industry: the moderating role of age

This study examines the degree to which construction sector employees perceive that safety is important in their organizations/sites and how job satisfaction affects these perceptions when age is introduced as a moderator variable. Two-way analysis of variance demonstrated that job satisfaction has a strong effect on perceived management commitment to work safety and that this relationship was moderated by respondents’ age. Job satisfaction was associated with perceived accident rate and safety inspection frequency, but the proposed role of age in this linkage was not confirmed. Consequently, the findings indicated that by increasing the level of job satisfaction, perceptions of these safety climate aspects proved to be more positive. The conclusion is that these relationships could further lead to a lower percentage of accidents and injuries in the workplace and better health among employees. A significant relationship between job satisfaction, age and perceived co-workers’ commitment to work safety was not found.     

事故调查分析方法与技术述评

根据事故的原因结果模型、过程模型、能量模型、逻辑树模型、SHE管理模型将事故调查分析技术方法归纳为5大类,介绍了广泛使用的事故调查分析技术方法的特点,并按一定的标准进行分析和比较。分析表明:每种方法都有其不同的应用领域和优缺点,应针对不同领域问题选用合适的分析方法,多种调查技术组合分析适用于复杂事故的调查;考虑事件次序及其影响因素的调查方法,便于提出预防事故再次发生和减少风险的建议,图表阐述有利于鉴别信息缺陷,并使调查组之间的沟通有力;笔者在调查过程中注重于非正常分析方法得出的结果,宜采用更为先进的事故分析技术方法以保证事故调查的客观性。     

工程项目施工安全保证的投入效率分析

利用ALARP原则构建工程项目施工风险可容忍区域,对处于不可容忍区域的安全事故,采取安全投入措施使之进入可容忍区域;对处于可容忍区域的安全事故,进行安全投入效益分析,以确定最佳安全投入额。采用事故树分析法探究事故与事故发生原因之间的内在逻辑关系,并探讨安全投入与事故发生概率的函数关系。在此基础上,构建安全投入优化分配模型,结合历史统计数据,利用Lingo软件对模型进行计算求解。     

Examining the asymptote in safety progress: a literature review

Many industries are confronted by plateauing safety performance as measured by the absence of negative events – particularly lower-consequence incidents or injuries. At the same time, these industries are sometimes surprised by large fatal accidents that seem to have no connection with their understanding of the risks they faced; or with how they were measuring safety. This article reviews the safety literature to examine how both these surprises and the asymptote are linked to the very structures and practices organizations have in place to manage safety. The article finds that safety practices associated with compliance, control and quantification could be partly responsible. These can create a sense of invulnerability through safety performance close to zero; organizational resources can get deflected into unproductive or counterproductive initiatives; obsolete practices for keeping human performance within a pre-specified bandwidth are sustained; and accountability relationships can encourage suppression of the ‘bad news’ necessary to learn and improve.     

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。     

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.     

An application of data mining tools for the study of shipping safety in restricted waters

The effectiveness of the enforcement of the ISM-Code and the examination of its role in the distribution of causes of shipping accidents between human and non-human error was studied. All accidents involving Greek-flagged ships from 1995 to 2006, a time-scale which spans over the pre- and post-ISM period in navigational regions of restricted waters, were analyzed.The accident data was processed through a classification tree analysis which enabled the classification of various accident factors. The analysis revealed that although the human error maintained its position as the dominant factor in shipping accidents, there is also substantial evidence in support of the ISM-Code effective control over shipping accidents during the post-ISM period. The implementation of the ISM-Code led to an overall reduction of human-induced accidents in total. Furthermore, in terms of location, the ISM-Code improved the human-induced accident record within restricted waters.Conclusively, the ISM-Code constitutes an effective policy measure for shipping safety. The results of the classification tree analysis reported in the present work can be used by decision makers in companies and international organizations to build knowledge-based expert systems and augment their information in the field of safety policy and management.     

A modified accident analysis and investigation model for the general aviation industry: Emphasizing on human and organizational factors

IntroductionCurrently, there is a lack of specific analytical tools for general aviation accidents (GAAs). This has led to loopholes in the prevention of GAAs.MethodsA Swiss Cheese model for general aviation (SCM-GA) is proposed to identify the human and organizational factors involved in GAAs. In the proposed SCM-GA, 5 categories, 45 subcategories, a general aviation safety management system (GA-SMS) and safety culture were developed based on the classic accident causation models combined with the laws and regulations and safety management practices in the general aviation industry.ResultsOne GAA was analyzed using SCM-GA. The human and organizational causes revealed by SCM-GA were more complete than the causes revealed through the accident report. The identification results of the deficiencies in the subcategories of GA-SMS and the safety culture were more consistent with the requirements in the general aviation laws and regulations than the organizational factors in the accident report. Based on the subcategories of SCM-GA, 41 GAAs that occurred between 1996 and 2010 in China were statistically analyzed and χ² test analyses were performed to estimate the statistical strength of the association between two adjacent subcategories of SCM-GA. The results showed that two adjacent subcategories of SCM-GA were significantly associated. They helped to determine the hidden problems in the accident report based on the path of accident.ConclusionsSCM-GA is an accident analysis tool that can comprehensively analyze the human and organizational deficiencies involved in GAAs. The accident causes revealed by SCM-GA were more consistent with the general aviation safety management practices.Practical applicationsGeneral aviation companies should establish their own GA-SMS and safety culture based on the subcategories developed herein. Using SCM-GA for routine safety inspection and accident investigation will help the management and the staff make effective safety decisions to effectively prevent GAAs.     

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.