行为安全视角下的氨泄漏事故分析

Analysis of Ammonia Leakage Accident from the Behavior-based Safety Perspective

为了提高涉氨制冷企业的安全业绩,基于事故致因"2-4"模型分析典型氨泄漏事故的直接、间接、根本和根源原因。结果表明:氨泄漏事故的直接原因是操作人员在涉及氨制冷管道、有毒有害环境及带电作业中的违章操作和氨设备设施的不安全物态;间接原因是员工对于氨危险性认识的不足、较差的安全习惯以及安全意识不高;根本原因是组织缺失特定的安全管理组织程序,制度执行不力;根源原因可追溯到员工对安全的重要度、安全制度执行方式等安全文化元素理解不到位。进而提出实用性对策措施,为提高涉氨制冷企业安全管理水平提供理论依据与技术参考。

In order to improve the safety performance of ammonia-related refrigeration enterprises, the 24 Model is used to analyze the direct, indirect, radical and root causes of typical ammonia leakage accident. The results show that the direct cause of the ammonia leakage is the unsafe acts of the violate operation in ammonia cooling pipeline, deleterious environment and hot-line work, and unsafe conditions of ammonia equipment, that the indirect cause is the lack of knowledge of ammonia risk, poor safety practices, physiology and psychology, that the radical reason is lacking a specific safety management organization program, and not well implementing the system, that the root cause can be traced back to the insufficient understanding of safety importance and implementation and other safety elements. Based on the above results, some practical measures are put forward to provide a theoretical basis and technical reference for improving the safety management level of ammonia-related refrigeration enterprises.