油气管道运营企业未遂事件管理探索与实践

为有效防范事故风险,本文以某油气长输管道运营企业为例,从未遂事件的判定标准、信息上报与通报、调查与处理、学习及经验分享4个方面介绍未遂事件管理机制,并通过统计分析2017-2022年未遂事件数据,说明未遂事件对隐患管理的促进意义、对生产管理策略的影响,为今后油气管道运营企业加强安全管理提供指导。     

长输管道未遂事件管理研究

未遂事件机理和事故机理是一致的,研究未遂事件管理过程和注意事项,可为防控事故发生提供有效支撑。首先介绍未遂事件基本概念及其管理框架。分析长输管道未遂事件管理特征并提出相关问题解决方案,主要包括免责报告制度、长输管道未遂事件等级划分、建立专门的长输管道未遂事件数据库、未遂事件教育培训等。其次面向长输管道未遂事件给出专门的上报管理流程,并针对国内某输气管道未遂事件进行案例管理分析。研究表明:近年来我国长输管道未遂事件主要原因为第三方破坏,通过原因分析,确立预防和控制措施,能有效确保管道安全运行。     

认知偏差下地铁施工中未遂事件影响及预防分析

针对目前地铁施工过程中存在的具有隐患特质的未遂事件、忽略隐式证据等现象,从认知偏差角度发掘隐式证据;标准化未遂事件,通过文本挖掘识别黑暗事件(残缺事件和隐藏事件),与完整事件组成未遂事件库;将未遂事件梳理成初始未遂事件链,通过数理统计方法,探寻机会因素影响下未遂事件的影响因素、方式和两类事件网,并分级未遂事件;制定预防机制,采用蜜罐技术和权变管理进行未遂事件双重预防设计,应用可靠性对预防效果进行动态测度,借助韧性评价进行实时监控,验证预防措施效果。通过分析,完善"隐患即事故"的理念和方法,丰富和发展地铁工程安全管理理论,为提升地铁安全管理水平提出有效建议。     

加强差错管理是预防事故的有效措施

所谓差错,即包括未遂事故、非伤害事故和违章指挥及违章作业事件。美国安全管理工程师海因里希提出的伤亡事故发生规律为 死亡重伤事故;重伤事故:无伤事故=1:29:300,推而广之,未遂事故多于“真实”事故。由于对差错心中无数,因而“小题大做”、“防微杜渐”等等就无从谈起。 为了加强对差错的管理,把工作做在事     

地铁盾构施工安全风险规律分析与对策

为预防地铁盾构施工安全事故,利用迭代自组织数据分析算法(ISODATA)对收集到的57起事故和186个未遂事件报告结构化数据进行聚类分析;通过对比分析各聚类集群相对风险可能性的量化结果,探讨地铁盾构施工的安全风险规律及管理对策。结果表明:始发-到达阶段地质条件复杂、洞口土体加固及降水不当是地铁盾构施工领域最危险的风险因素;针对事故风险较大的盾构始发-到达阶段,运用施工安全生产工艺学方法作为安全风险管理对策,可提高地铁盾构施工安全管理绩效。     

从事故信息隐蔽性角度看未遂事故管理

正安全事故和未遂事故虽然都属于事故管理范围,但不应采取相同的管理思路进行处理。笔者将站在事故管理全流程的角度,来分析安全事故和未遂事故管理的区别。首先,重新认识事故管理全流程内容。传统观念认为,事故管理包括事故原因分析、事故责任追究、整改措施落实、事故教训举一反三。但是笔者认为,事故管理的全流程应当按照流程顺序划分5个阶段,分别为:获取事故信息、原因分析、问题整改、教训推广、责任分析。     

高校突发事件的预防与应对机制研究

为预防校园突发事件,补齐高校校园安全管理的短板,本文分析高校突发事件的概念、特征、发生原因及危害,提出高校常态管理机制,该机制包含静态的日常管理体系建设和动态的风险紧急举报程序。静态的日常管理体系由学校责任、机构建设、人员配备,以及机构的制度建设等方面构成;动态的风险举报程序对未造成严重后果的未遂事件进行管控。     

生产安全重特大事故和重大未遂伤亡事故信息处置办法(试行)

本期政策法规附刊要目:生产安全重特大事故和重大未遂伤亡事故信息处置办法(试行)国务院关于进一步加强消防工作的意见关于加强危险化学品道路运输安全管理的紧急通知安监总调度[2006]126号发布日期:二○○六年七月二日为适应全国安全生产新形势新情况的要求,建立快速反应、运行有序的信息处置工作机制,进一步规范安全生产监督管理、煤矿安全监察、应急救援,指导协调有关部门做好生产安全重特大事故和重大未遂伤亡事故的信息处置和现场督导工作,制定本办法。一、重特大事故和重大未遂伤亡事故范围(一)一次死亡30人以上(含30人,下同)特别重大…     

基于失效模式的电力企业事故分析系统构建

为确保电力企业安全生产高效运行，根据事故致因理论和安全系统过程的基本原理，建立基于失效模式的事故分析系统，分析已发生的事故、违章、未遂等管理失效点的数据，揭示人员行为表现形式。结果表明：人为、组织、管理等因素共同导致管理流程失效；人因失误和管理失效是事故发生的最主要原因，占比均达40%以上，组织管理失效占比达到11%以上，而设备原因占比仅为6%;传统分析方式对组织和制度原因分析较少，多从个人角度找原因，管理原因深度不够，多停留在事件表面。通过事故分析，确定对应的失效模式，找到对应的解决策略，识别与控制潜在的安全风险。     

高度重视未遂事故

美国著名安全工程师海因·里希对55万余起工伤事故的统计分析发现,严重伤害事故、轻微伤害事故和非伤害事故发生的比例关系是1：29：300。其中,发生频次最高的非伤害事故,也被称为未遂事故。大量的未遂事故是构成作业现场危险的真实写照．也是企业安全生产事故频发的诱因之一．许多事故就是在这一起起未遂事故的容忍和忽视中发生的。因此,要杜绝安全事故,必须避免未遂事故的发生,必须高度重视对未遂事故的管理．     

基于有序Probit模型的铁路险兆事件影响因素识别研究*

为识别铁路险兆事件的影响因素,以宜春车务段2017年9月—2017年10月共1 870条数据为样本,以铁路险兆事件等级为因变量,事件原因、环境特征和事件特征为自变量建立有序Probit模型,探究人、设备、环境和管理因素对铁路险兆事件严重影响程度。研究结果表明:设备设施未按规定防护是影响严重性险兆事件发生的主要因素;与其他人为因素相比,未执行相关作业规定对增加险兆事件严重程度有显著作用。研究结果可为铁路管理部门实现事故预控提供依据。     

Analysis of car-to-bicycle approach patterns for developing active safety devices

Objective: To reduce the severity of injuries and the number of cyclist deaths in traffic accidents, active safety devices providing cyclist detection are considered to be effective countermeasures. The features of car-to-bicycle collisions need to be known in detail to develop such safety devices.

Methods: The study investigated near-miss situations captured by drive recorders installed in passenger cars. Because similarities in the approach patterns between near-miss incidents and real-world fatal cyclist accidents in Japan were confirmed, we analyzed the 229 near-miss incident data via video capturing bicycles crossing the road in front of forward-moving cars. Using a video frame captured by a drive recorder, the time to collision (TTC) was calculated from the car's velocity and the distance between the car and bicycle at the moment when the bicycle initially appeared.

Results: The average TTC in the cases where bicycles emerged from behind obstructions was shorter than that in the cases where drivers had unobstructed views of the bicycles. In comparing the TTC of car-to-bicycle near-miss incidents to the previously obtained results of car-to-pedestrian near-miss incidents, it was determined that the average TTC in car-to-bicycle near-miss incidents was significantly longer than that in car-to-pedestrian near-miss incidents.

Conclusions: When considering the TTC in the test protocol of evaluation for safety performance of active safety devices, we propose individual TTCs for evaluation of cyclist and pedestrian detections, respectively. In the test protocols, the following 2 scenarios should be employed: bicycle emerging from behind an unobstructed view and bicycle emerging from behind obstructions.     

The role of risk avoidance and locus of control in workers’ near miss experiences: Implications for improving safety management systems

The process industry has made major advancements and is a leader in near-miss safety management, with several validated models and databases to track close call reports. However, organizational efforts to develop safe work procedures and rules do not guarantee that employees will behaviorally comply with them. Assuming that at some point, every safety management system will need to be examined and realigned to help prevent incidents on the job, it is important to understand how personality traits can impact workers' risk-based decisions. Such work has been done in the mining industry due to its characteristically high risks and the results can be gleaned to help the process industry realign goals and values with their workforce. In the current study, researchers cross-sectionally surveyed 1,334 miners from 20 mine sites across the United States, varying in size and commodity. The survey sought to understand how mineworkers' risk avoidance could impact their near miss incidents on the job – a common precursor to lost-time incidents. Multiple regressions showed that as a miner's level of risk avoidance increased by 1 unit in the 6-point response scale, the probability of experiencing a near miss significantly decreased by 30% when adjusting for relevant control variables. Additionally, a significant interaction between risk avoidance and locus of control suggested that the effect of risk avoidance on near misses is enhanced as a miner's locus of control increases. A one-unit increase in locus of control appends the base effect of risk avoidance on near misses with an additional 8% decrease in the probability. Findings are discussed from a near-miss safety management system perspective in terms of methods to foster both risk avoidance and locus of control in an effort to reduce the probability of near misses and lost time at the organizational level within the process industry and other high-hazard industries.     

Near-Miss定义及管理流程分析

作为事故金字塔的基座,Near-Miss管理在企业HSE管理乃至整个企业管理中起着非常重要的作用。通过消除底部的Near-Miss,可以最大限度地消除隐患,避免顶端意外事件的发生,提升企业HSE业绩,提高企业的运行效率。通过比较分析,可将Near-Miss翻译为"虚惊事件"。一个完整的Near-Miss管理可分解为八个流程,每个流程缺一不可,且前面的流程决定了后面流程的完成情况。通过八个流程的充分运行,可以获得Near-Miss管理效益的最大化,最终提升企业的HSE管理水平。     

基于TEM模型的民航不安全事件关联规则挖掘与分析*

为了预防民航不安全事件的发生,应用机组威胁与差错管理（TEM）模型分析2014—2020年民航事故/征候的航空安全报告资料,提取事件里存在于民航运行风险中潜在的情况、威胁、机组差错等因素,通过改进的关联规则方法挖掘其中的关联关系,包括挖掘与事件严重程度有关的因素,找到TEM模型中的关键因素和影响航空器结束状态的致因因素,并进行关联网络图分析。研究结果表明:手动操纵/飞行控制差错、缺少/不足的飞行培训和安全管理、飞行员之间沟通差错与程序执行错误是造成事故/征候的显著因素;关联规则能够有效利用航空安全报告信息,通过定量的方法挖掘事故/征候的特征,找到影响民航不安全事件的强关联因素,为民航安全管理人员提供决策依据。     

Safety management systems and safety culture in aircraft maintenance organisations

A self-regulatory model was proposed to examine how different organisations manage safety, with particular emphasis on the human and organisational aspects. The relationships of different aspects of safety culture and safety management systems were explored through the deployment of different research measures and methods. Studies of four aircraft maintenance organisations included analysis of documentation and qualitative interviews, surveys of safety climate and attitudes, expected response to incidents and compliance with task procedures. The model was effective in analysing the salient features of each organisation' s safety management system, though it underestimated the roles of planning and change. The data from management interviews, the incidents survey and safety climate survey exhibited a large measure of agreement in differentiating between the different safety management systems and safety climate of the four organisations. The measures of compliance with task procedures and safety attitudes did not differentiate between the four organisations (though one organisation did differ from the others in safety attitudes). This suggests a strong, relatively homogeneous professional sub-culture of aircraft technicians spanning the different organisations. Differences in safety attitudes and climate were found between occupational groups, though in the case of climate the differences between occupational groups were a function of the organisation, suggesting a differentiated notion of safety culture. The professional sub-culture of technicians is likely to mediate between the organisation' s safety management system and safety outcomes.     

学校突发事件应急管理存在的问题及解决对策研究

阐述学校突发事件的定义,针对目前学校安全的严峻形势和现状,分析了学校突发事件应急管理的重要性。基于应急管理理论,剖析我国学校突发事件特点。通过对学校安全应急管理体制系统的分析,指出存在的主要问题,进而提出可行性对策:必须构建统一的学校安全应急管理体制、建立健全应急管理机构、充分发挥各级政府效能,完善应急预警。最后,提出加强学校突发事件的应急管理,有必要建立学校安全应急指挥决策系统;完善我国学校安全法律法规与标准体系;必须建立一个科学、系统、全面的学校安全应急管理体制。     

中国民航业安全风险监测与仿真研究

根据系统安全的思想,通过对航空安全历史数据的分析和专家经验,从人员、设备设施、环境和组织管理4个方面,提出中国民航机务、空管、飞行、机场4个分系统安全风险监测指标体系,共102个风险因素指标,并合成为27个行业安全风险监测指标。以民航历史数据为样本,建立资源优化神经网络(RON)模型,将安全风险监测指标与中国民航安全指数相联系,分析安全指数的关键影响因素,达到安全管理决策支持的目的。通过建立的风险监测指标体系和RON模型,可以实现民航整个行业、各分系统及单个指标的安全风险监测和预警。     

Analysis of bus collision and non-collision incidents using transit ITS and other archived operations data

Introduction

This paper analyzes factors contributing to bus operations safety incidents at TriMet, the transit provider for the Portland Oregon metropolitan region.

Method

The analysis focuses on 4,631 collision and non-collision incidents that occurred between 2006 and 2009. Empirical analysis of these incidents draws on a wide array of operator-level data recovered by transit ITS technologies in combination with information from TriMet's human resources, scheduling, and customer relations databases. Incident frequencies are estimated in relation to operators' demographic characteristics, employment status, assigned work characteristics, service delivery and performance indicators, temporal factors, and customer information.

Results

Apart from identifying factors that are empirically related to the frequency of safety incidents, the findings offer insights into operations policies and practices that hold promise for improving safety.

Impact on Industry

Potential for safety improvement based on analysis of archived operations and human resource data.     

基于扎根理论的煤矿运输险兆事件影响因素研究

为了科学预防并控制煤矿运输险兆事件发生,需明确煤矿运输险兆事件影响因素,以便采取相应的管控策略。在文献研究与调研访谈的基础上,运用扎根理论质性研究方法,深入分析访谈资料及煤矿运输险兆事件案例,通过开放性译码、主轴译码、选择性译码、理论饱和检验等环节对煤矿运输险兆事件影响因素进行研究。结果表明,安全培训、安全意识、监督检查等16个主范畴对煤矿运输险兆事件有影响,从中选择4个核心范畴,即运输设备系统、运输作业场所、组织管理体系、工作人员素质,概括为物理性因素与行为性因素,构建了包含2个主要因素、4个核心范畴及16个主范畴的煤矿运输险兆事件影响因素评价指标体系,最后提出了推行标准作业流程、建立管理机制、加强安全文化建设、开展闭环教育培训等策略,减少并预防煤矿运输险兆事件的发生。