工业事故调查与分析的发展历程及趋势

工业事故调查伴随着工业革命的发展而开展,而事故分析,特别是系统的分析开展于上世纪的五六十年代。事故调查和分析研究的发展历程可以分成四个阶段,单一原因-结果阶段、多原因-结果阶段、系统化分析阶段以及产业化发展阶段。事故调查和分析从最早的仅仅查找事故（直接）原因单一目的,发展到现在查找（根本）原因、分析原因、制定措施、监督执行等多个目的。事故调查和分析已经发展成为一个学科,一种职业。事故调查和分析的理论和方法也从最初的单方面、表面、短期发展到了全面、深入和系统化。本文在介绍事故调查和分析的发展阶段和过程的同时还将对各阶段代表性的调查方法和理论给予介绍,主要包括＂鱼骨（F ishbone）图＂、＂领结图（BowTie）＂、＂直根（Taproot）图＂和＂三脚架（Tripod）＂。

The track of industrial incident investigation and analysis and developing trends

Industrial incidents investigation study came along with industrial revolution,and root cause analysis,especially systematic analysis started in 50＇s and 60＇s last century.It could be said there are four stages in the development of incident investigation and root cause analysis,single Cause-Effect,Multiple Causes-Effect,Systematic Causes-Effect and Professional Causes-Effect Analysis.In early time,incident investigation and cause analysis focus on single,immediate and seemingly factors（causes）,and now,are to search root causes,recommend corrective actions and improve performance.Root cause analysis,today,have become a professional business.The incident investigation and analysis track and stages will be introduced and popular theories and practices,Fishbone,Bowtie—Fault Tree and Event Tree,Triopod and Taproot,in different stages will be described in this paper.