基于STAMP模型的石化企业硫化氢中毒事故分析

Analysis of Hydrogen Sulfide Poisoning Accidents in Petrochemical Enterprises Based on STAMP Model

应用STAMP模型,对一起硫化氢中毒事故进行了分析,分别从物理层、操作层、管理层考察了导致事故的控制缺陷、情景因素,找出了事故的深层次原因。案例应用结果表明,STAMP模型从系统论和控制论的角度分析事故,不局限于技术层面,分析的视角更广,并考虑了各方的交互反馈、系统动态变迁等系统性因素和事故发生的情景(背景)因素,提高了事故分析的系统性和科学性,在石化领域事故调查中具有广阔的应用前景。

In this paper,a hydrogen sulfide poisoning accident was analyzed by the STAMP model.The control deficiencies and situational factors that led to the accident were investigated from the physical layer,operational layer and management layer,and the underlying cause of the accident was found out.The application results showed that accidents were analyzed by the STAMP model from the perspective of systems and control,which was not limited to technical analysis,had a broader perspective.The systemic factors such as interaction feedback from various parties,system dynamic changes,and the scenario(background)factors of accident were considered,improving the systematicity and scientificity of accident analysis,and providing broad application prospects in the field of accident investigation.