复杂社会技术系统视角下民用瓶装LPG爆炸事故致因分析

Analysis of causal factors in civilian bottled Liquefied Petroleum Gas(LPG)explosion accidents from the perspective of complex sociotechnical systems

探讨民用瓶装液化石油气(Liquefied Petroleum Gas, LPG)爆炸事故致因,对保障公共安全意义重大。首先,收集中国内地2014—2023年110起民用瓶装LPG爆炸事故典型案例,明确事故系统特征;其次,由Rasmussen风险管理框架建立事故6级层次结构,基于事故查证资料辨识19项典型致因并建立AcciMap模型;最后,融合AcciMap与贝叶斯网络(Bayesian Network, BN)构建量化分析框架,通过诊断推理和敏感度分析辨识关键致因。结果表明:民用瓶装LPG爆炸事故拥有不安全行为和物态2条关键路径;安全生产监管与执法检查不力、违法违规或无资质经营与供气、安全生产主体责任未落实、安全管理和隐患整改存在缺陷、安全培训和应急管理存在缺陷、违规操作钢瓶或燃气器具、安全防护设备或措施存在缺陷是关键致因。应针对关键致因,从政府部门、经营单位、用户单位协同的视角采取靶向防治对策。

Exploring the causal factors of civilian bottled Liquefied Petroleum Gas(LPG)explosion accidents is crucial for preventing such incidents and ensuring public safety.First,we collected data on 110 typical cases of civilian bottled LPG explosions in China's Mainland from 2014 to 2023,allowing us to clarify the characteristics of the accident system.Next,the Rasmussen Risk Management Framework(RRMF)was utilized to establish a six-level hierarchical structure for accidents.Based on the verification materials related to these incidents,19 typical causal factors were identified,leading to the development of the AcciMap model.Finally,a quantitative analysis framework was developed by integrating the AcciMap model with a Bayesian Network(BN).Key causal factors were identified through diagnostic reasoning and sensitivity analysis.The results of the analysis reveal that civilian bottled LPG explosion accidents are driven by two key causal chains:unsafe behaviors and unsafe physical conditions.The key causal chain for‘unsafe behavior’is as follows:inadequate safety production supervision and law enforcement inspection(A 1)→failure to implement main responsibilities for safety production(C 1)→deficiencies in safety management and hazard rectification(C 2)→shortcomings in safety training and emergency management(C 3)→gaps in safety awareness and capabilities(D 1)→illegal operation of LPG cylinders or appliances(D 2)→LPG leakage and accumulation(F 1)→civilian bottled LPG explosion accident(F 2).The key causal chain for‘unsafe physical states’is as follows:inadequate safety production supervision and law enforcement inspection(A 1)→failure to implement main responsibilities for safety production(C 1)→deficiencies in safety management and hazard rectification(C 2)→flaws in safety protection equipment or measures(E 3)→LPG leakage and accumulation(F 1)→civilian bottled LPG explosion accident(F 2).There are seven key causal factors,which include:inadequate safety production supervision and law enforcement inspection(A 1),illegal or unqualified operation and supply of bottled LPG(B 2),failure to implement main responsibilities for safety production(C 1),deficiencies in safety management and hazard rectification(C 2),shortcomings in safety training and emergency management(C 3),illegal operation of LPG cylinders or appliances(D 2),and flaws in safety protection equipment or measures(E 3).The conclusion is that targeted risk prevention,control,and governance measures should be implemented through collaborative efforts among local government and regulatory agencies,as well as business and user units involved with civilian bottled LPG,to effectively address the key causal factors.