基于系统论的STAMP模型在煤矿事故分析中的应用

Application of STAMP model in coal mine accident analysis

为应对大量使用数字组件和构建复杂系统所带来的安全挑战，将系统工程的思想融入事故预防被认为是有效的应对方法．Systems-theoretic accident model and processes（STAMP）正是一种基于系统论的事故分析模型，目前已在航空航天、化工、医疗、交通安全等领域取得良好的应用．本文首次尝试使用STAMP模型详细分析一起煤矿事故，分别从物理过程、基层操作、直接监管、矿级监管和系统设计、省级监管及事故的动态过程等方面对导致事故发生的控制缺陷进行剖析，发现除技术原因和工人违章操作外，自下而上有12个组织机构存在控制错误，导致这些错误的关键原因是该系统分层控制结构中各层之间的反馈回路在系统外部环境改变后发生了变化．总之，煤矿事故是我国第一大生产事故，本文希望能提供一个更系统、广泛的视角，以帮助发现日益复杂的煤矿系统存在的安全隐患，减少类似事故发生的可能性．

The ever-increasing amount of digital components and the ever more complex systems have brought more challenges to safety. It＇s thus believed that systems theory once being implied into accidents prevention, will serve as an effective way to understand accident causation. Systems-theoretic accident model and processes （STAMP） is an accident model based upon systems theory, and has been widely applied to fields such as astronomy, chemical industry, medical services and transportation safety. This paper attempts to use the STAMP model to a coal mine for the first time, and analyzes the control flaws leading the accidents in the dimension of physical progress, first-level operation, direct regulatory agencies, company supervisory and system design, provincial government, and dynamics process. Results show that apart from technical reasons and the rule-breaking behaviors from the coal mine workers, there have been controlling mistakes in 12 organizational structures, resulting mainly from the changes of the feedbacks in different layers of the multiple-layer control structures after the shifts of the outside environment. All in all, given that coal mine accidents take up a large percentage of production accidents in China, we hope that the paper will provide a more systematic and comprehensive view on spotting ever more complex hazards so as to prevent future accidents.