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。     

协和客机坠毁事故调查始末

编者按: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.     

爆炸事故原因调查的研究

爆炸事故原因调查可以提供一些有用的信息 ,以避免同类事故的发生。笔者介绍了调查爆炸事故原因所需的材料 ,提出了爆炸事故调查相关的主要内容以及爆炸现场勘查的组织指挥 ,并以一个爆炸事故的调查作为实例进行了讨论。     

国外安全生产事故独立调查机制的启示

事故调查的根本目的是为了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，而保持事故调查的独立性达成此根本目的起着至关重要的作用。从事故调查的独立性进行考虑，剖析了事故调查的法律制定、调查机构、经济支持、技术与司法调查分离、公众知情权等独立性表现，分析了我国目前事故调查的工作现状及存在的一些问题。对比分析了发达国家的事故调查机构的独立运作机制和特点。最后，针对上述问题，对我国安全生产事故独立调查机制的建立提出了一些建议。     

硝酸塔闪爆事故原因分析与预防措施

本文针对硝酸塔内发生闪爆事故原因,从事故可能发生的过程采取排除方法进行了系统分析,确定事故的原因,并提出了控制和预防事故发生的措施.     

基于贝叶斯网络的煤矿事故人因推理

煤矿事故的不可重现性决定了事故原因的调查具有很强的不确定性,如何通过事故发生后的相关信息提高事故深层次原因调查的准确性是非常重要的。将HFACS与贝叶斯网络相结合,以煤矿事故HFACS分析结果为样本,通过卡方检验和让步比分析建立人因的贝叶斯网络因果图,进一步利用最大似然估计算法确定了煤矿事故人因的贝叶斯网络参数。最后,以双柳煤业顶板事故的调查信息为证据推理导致煤矿事故发生的深层次原因,提高事故原因调查的准确性,从而验证模型的有效性。     

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。     

变电运行事故的根原因分析

变电运行事故对人身、设备乃至电网危害很大,目前的事故调查偏于追究直接原因和直接责任,对预防同类事故发生效果欠佳.本文提出了一种事故根原因调查与分析骨牌模型,对直接原因、间接原因和基础原因进行了归类.借助该模型的根原因分析可以得出更为有效的整改措施,对变电运行事故防范具有重要意义.     

对一起雷电事故的调查与分析

对一起雷电事故的调查与分析●冯儒翰９０年代初，我们调查处理过一起发生在我国西北部，年平均雷暴日低于２０日的地区的雷击事故。事故经过及原因，在今天看来仍不乏经验教训可汲取。一、事故经过当年６月１０日下午，地处宁夏北部的红岗小学发生了一起罕见的雷击事故...     

事故调查的哲学原理

进行事故调查的一个根本目的,就是预防事故以致最终消灭事故。为实现这一目的,事故调查必须遵循基本的哲学原理。事故调查的各个环节表现为相互联系相互依存的紧密关系事故调查的主要任务是,查找事故原因,总结事故教训,制定和落实预防事故、改进工作的措施。这是事故调查的精髓所在,是事故预防的根本途径。事故原因是按照事故致因理论,采用取证、实验、推理以及其他科学方法,     

化工火灾事故调查方法研究

为克服化工火灾调查中人为因素的影响,增强事故调查的科学性和准确性,在总结化工火灾现场特点的基础上,提出化工火灾事故调查时应遵循的假设推理法,通过证据收集、分析资料、建立假设、检验假设和选择假设,构建化工火灾事故调查的证据系统,包括实物证据,位置证据、文件证据和人证,从火灾动力学角度分析了火灾痕迹的影响因素。结果表明:假设推理法重视证据收集,综合使用归纳推理和演绎推理,有助于避免主观判断的影响;采用系统方法收集证据,扩大证据收集的范围,列举证据清单和优先考虑敏感性证据的方法有助于提高调查效率;火灾行为、材料的热响应和灭火行动对火灾痕迹的形成有直接影响,分析时应充分考虑,以免作出错误的判断。     

Case study of a nylon fibre explosion: An example of explosion risk in a textile plant

This paper offers an overview of an explosion that occurred in a textile industry, due to the deflagration of a particular nylon fibre called flock. The evidence, the methods and the results of the inquiry are reported. The explosion occurred in a plant that produced a characteristic kind of flocked thread which is entirely made of a synthetic material. The explosion took place inside a dryer and propagated to the connected suction plant. The explosion occurred when the plant was switched on after a long stop due to a process fault. Three workers were injured. The inquiry includes the measurement of the most important properties of the flock such as the minimum ignition energy (MIE) and the lower explosion concentration (LEL), together with an examination the exam of the damage and of the testimony of the witnesses. The dynamics of the event are reconstructed in the paper and the effects, on the accident, of the many mistakes that have been made in the risk analysis are highlighted and discussed.     

基于动态风险平衡的海洋平台事故连锁风险研究

针对海洋平台事故风险特点,提出动态风险平衡概念,以此建立事故动力模型,并将该模型运用到墨西哥湾"深水地平线"井喷事故。动态风险平衡表征事故动力与事故阻力之间的动态平衡状态,具有动态性和暂时稳定性。事故动力模型以海洋平台可能发生的重大事故为研究对象,从工艺、技术和管理等角度分析事故可能致因和事故发展可能影响因素。该模型首先分析对象的初始事故动力,建立事故连锁风险图,然后计算初始动力发生情况下,传递动力和传递阻力的概率分布,最后提出相应风险控制措施。实例分析表明,基于动态风险平衡建立的事故动力模型能有效分析海洋平台事故连锁风险。     

Whiplash-associated disorders in frontal impacts: influencing factors and consequences

This multidisciplinary in-depth investigation of accidents using 24 occupants with neck symptoms shows the complexity of whiplash-associated disorders (WAD) in frontal impacts with respect to factors that influence occurrence as well as duration of symptoms. Several different occupant kinematics have been identified, all resulting in symptoms classified as WAD. Compared to occupants restrained only by a seat belt, occupants with arm resistance influence showed a greater representation of symmetrical neck symptoms. Two cases of unbelted occupants with a neck compression mechanism far from conventional "whiplash" motion were found. Posture as well as physical and psychosocial factors such as strong negative reactions, bad prognosis expectation, and stressed daily activities influenced the duration of symptoms. Occupant characteristics and sitting posture and behavior at the time of impact are important factors when analyzing and understanding WAD.     

核电厂HRA定性分析

人因可靠性分析(HRA)是核电厂概率安全评价(PSA)的重要组成部分,定性评价对核电厂庞大的数据进行筛选和分析,是HRA的基础和出发点.本文介绍了核电厂HRA定性分析的目的、原则、方法和程序,并以压水堆核电厂蒸汽发生器传热管破裂(SGTR)为具体实例进行说明.     

Prerequisites for learning from accident investigations – A cross-country comparison of national accident investigation boards

In this paper railway accident investigation reports issued by the national accident investigation boards in three Scandinavian countries during a 2-year period have been systematically studied. Content analysis of attributed causes in these reports reveals a considerable emphasis on physical processes, actor activities and equipment (the microlevel). Much less attention is paid to organisational factors (the mesolevel) and conditions related to regulators, associations and government (the macrolevel). This means that lessons will primarily be learned about aspects at the lower of these levels. Interviews show that the factors emphasised in investigation reports typically reflect the competences and experiences of the investigators, i.e. they are inclined to focus on areas of their own expertise. Since failures at the microlevel in many cases merely are symptoms of trouble at higher levels, it is argued that competence among investigators that supplements entirely technical or operational backgrounds are necessary for enabling deeper understanding of the factors leading to accidents. One possible way for achieving this is the creation of multi-modal investigation boards that provide a number of potential advantages, such as increased access to specialist competences that are shared between different sectors. Although a multi-modal approach to some degree has been adopted in all three countries, interviews reveal that these positive effects do not emerge automatically. It can therefore be concluded that multi-modal investigation boards offer a number of possible advantages, but only when these synergies are fully exploited can they provide a potential for more effective learning from accidents.     

基于物元分析法的古建筑火灾风险评价

古建筑火灾风险评估是突发事件应对中"关口前移"的体现,以物元分析法为基础提出了古建筑火灾风险评价的物元模型,并对某世界名镇内古建筑进行风险评估。首先,在火灾风险影响因素的事故树分析基础上,选取能够反映古建筑火灾风险特性的51个指标作为评价指标体系;其次,建立古建筑火灾风险评价的物元模型;最后,根据实地调研数据进行标准化赋值,实现对古建筑火灾风险的定量化评价,通过评价方法对比验证了模型有效性和先进性。结果表明,所评价建筑的总体关联度系数为-0.248,四项"优秀"级别指标关联度分别为-0.129、-0.183、-0.211、-0.216,两项"较差"级别指标关联度为0.025、-0.016,表明所评价建筑火灾风险等级的显性结果为"优秀"级别,但隐性结果为"良好+"级别,火灾风险等级潜在提升能力较强。     

An expert system for the quantification of fault rates in construction fall accidents

Introduction. Expert witness reports, prepared with the aim of quantifying fault rates among parties, play an important role in a court's final decision. However, conflicting fault rates assigned by different expert witness boards lead to iterative objections raised by the related parties. This unfavorable situation mainly originates due to the subjectivity of expert judgments and unavailability of objective information about the causes of accidents. As a solution to this shortcoming, an expert system based on a rule-based system was developed for the quantification of fault rates in construction fall accidents. The aim of developing DsSafe is decreasing the subjectivity inherent in expert witness reports. Methodology. Eighty-four inspection reports prepared by the official and authorized inspectors were examined and root causes of construction fall accidents in Turkey were identified. Using this information, an evaluation form was designed and submitted to the experts. Experts were asked to evaluate the importance level of the factors that govern fall accidents and determine the fault rates under different scenarios. Based on expert judgments, a rule-based expert system was developed. The accuracy and reliability of DsSafe were tested with real data as obtained from finalized court cases. Result. DsSafe gives satisfactory results.     

The determinants of job seekers' reputation perceptions

Although job seekers' reputation perceptions may be based on different factors than other constituents (e.g., investors, consumers), we know little about the antecedents of job seekers' reputation perceptions. The present study utilizes verbal protocol analysis to explore the factors that job seekers consider when evaluating employers' reputations. Results from this qualitative investigation are complemented and cross‐validated with an experimental policy capturing study and a field study of recruiting organizations. Data from all three methodologies suggest that some factors affecting job seekers' reputation perceptions are quite different from factors that have been revealed in previous reputation research, which has focused primarily on executives. For example, results from the present study reveal that the type of industry in which a firm operates, the opportunities that a firm provides for employee development, and organizational culture affect job seekers' reputation perceptions. Copyright © 2000 John Wiley & Sons, Ltd.     

地铁项目安全绩效关键影响因素分析研究

在分析研究地铁安全事故案例的基础上,识别出对地铁项目安全绩效的48个关键影响因素,将这些影响因素归为五大类,即项目参与各方对安全的影响程度、人员的不安全行为及不安全状态、材料的不安全状态、机械/设备的不安全状态和现场环境的不安全状态;采取调查问卷的方式,运用结构方程建模得出各个指标的重要度及各指标之间的相互影响。研究结果表明:"项目参与各方对安全的影响程度"和"现场环境的状态"对地铁安全绩效的贡献最大,同时,其他因素也有较强的影响,在地铁施工中应以此为重点,加强安全防范。