基于累积效应的事故进程研究

Research on accident process based on cumulative effect

为研究事故孕育与发展过程中失误的积累作用,引入累积效应的研究思想。首先,运用理论分析、案例研究等方法,分析事故中失误的累积特点,研究失误的累积效应与事故发展过程的关系;然后,基于失误的累积效应将事故进程划分为6个阶段,在此基础上构建基于失误累积效应的事故致因模型,明确在每一阶段失误的累积特点;最后,将该模型应用于案例分析,验证模型在分析具体事故时的有效性与可行性。研究表明:在企业社会技术系统中,事故是失误逐步累积并由触发事件触发导致,事故预防的源头措施是安全文化建设。

In order to study accumulation effects of errors during accident incubation and development process,a research idea of cumulative effects is introduced. Firstly,cumulative characteristics of errors were analyzed with methods of theory analysis and case study to explore relationship between cumulative effects of errors and occurrence of accidents. Then based on these effects,accident process was divided into six stages,and an accident causation model on the basis of fault accumulation effects was constructed to clarify their cumulative characteristics at each stage. Finally,this model was applied to a case study to verify its effectiveness and feasibility in analysis of specific accidents. The research shows that accidents are caused by cumulative errors and triggered by triggering events in socio-technical systems of enterprises and safety culture development proves to be a fundamental measure for accident prevention.