组态视角下煤矿事故恶化路径的清晰集定性比较分析

A crisp-set qualitative comparative analysis of deteriorating path of coal mine accidents from the configuration perspective

为减少煤矿事故的发生、防止事故进一步恶化,以44起煤矿事故及险兆事件为对象,基于改进的REASON理论框架构建不安全因素属性表,运用清晰集定性比较分析法(csQCA)进行组态分析,探究从险兆事件到一般事故再到较大及以上事故的致因路径及核心因素,力求找出事故的恶化路径与关键因素。结果表明:通过单因素必要性分析,发现“组织制度缺陷”与“风险辨识失效”是煤矿事故发生的必要条件;分析得到10种一般事故、8种较大及以上事故的组态解,聚类归纳出设备缺陷、制度缺陷、操作风险与监管缺失4种事故类型;通过对一般事故与较大及以上事故交集组态的对比分析,发现“技术管理缺陷”与“属地监管不力”2种不安全因素是导致事故恶化的关键所在;根据不同事故类型,针对事故恶化的核心条件提出预防与应对措施。

In order to reduce the occurrence of coal mine accidents and prevent further deterioration,this paper conducted a configuration analysis by adopting the ctisp-set qualitative comparative analysis method(csQCA)and built an attribute sheet of unsafe factors based on the improved theoretical framework of REASON.And 44 coal mine accidents,including near-miss incidents,were taken as the object with the efforts of finding the deteriorating path and core factors of these accidents from near-miss to general and major conditions.The results show that,according to the analysis of mono-factor,the defects of organizational system and ineffectiveness of risk awareness were found essential to result in an accident.The configuration solutions of ten general accidents and eight larger and major accidents were examined,and four types of incidents,namely,equipment defects,operation risks,defects of organizational system and lack of supervision were also categorized.Through the comparative analysis of intersection configuration between general accidents and larger and major,is was found that technology management deficiencies and ineffective territorial supervision play the key role to the deterioration of the accident.Finally,prevention and countermeasures for the core conditions of accident deterioration were also presented with different types of incidents.