重大事故根源分析的周易社会层级模型研究  

Study and Analysis of the Root Cause Analysis in Zhouyi Social Hierarchical Model for Major Incidents

作　　者：徐卫东 刘祖德[2] 吴斐[2] 聂从 

机构地区：[1]深圳市佳保事故预防研究院,广东深圳518067 [2]中国地质大学(武汉)工程学院,湖北武汉430074

出　　处：《安全与环境工程》2017年第5期132-137,共6页Safety and Environmental Engineering

摘　　要：重大事故的发生有着多重的致因因素,目前国内流行的事故调查与分析主要是针对企业或者组织内部的人因与管理失误,缺乏对事故社会原因的分析与探讨。将国际上流行的事故致因理论与中国的传统文化周易相结合,提出了重大事故根源分析的"周易社会层级模型"假设,将重大生产安全事故的致因调查与根源分析划分为六个社会层级因素与防护屏障,包括直接原因(危险监控层)、间接原因(作业控制层)、系统原因(管理体系层)以及社会原因(公司治理层、标准规范层和法律法规层),并以此为基础开发出周易社会层级模型的重大事故根源分析工具。通过该模型在重大事故调查与根源分析实际案例中的应用,结果表明该模型不仅可以分析时间事件链中每个关键事件或状态的直接原因、间接原因和系统原因,还能找到公司治理、标准规范和法律规范等方面的社会原因,可为重大事故的调查与根源分析提供参考思路、方法和工具。The occurrence of major incidents has multiple causal factors. Current accident investigations and analysis usually focus on human factors and management failure of the organization in China, and are defi- cient in a deeper analysis and probe of social factors. The paper combines the international popular incident causation theory with the traditional Chinese Zhouyi philosophy to develop the Zhouyi Social hierarchical Model for the root cause analysis of major incidents. The paper divides social causes of major incidents into six layers and protective barriers, namely, direct causes （hazard monitoring）, indirect causes （control of work） ,system causes （management system） and social causes （including corporate/enterprises govern- ance, standards and specifications,and regulations and laws）, and based on this the paper also develops the root cause analysis tool of zhouyi social hierarchical model. The application of the model in the case study of major accident investigation and root cause analysis shows that the model can not only analyze the immedi- ate cause, indirect cause, and systematic cause of each key event and state in the event chain, it can also finds the social causes of corporate governance, standards, laws and regulations, and can provide reference for the investigation and root cause analysis of major incidents.

关 键 词：周易社会层级模型 重大事故调查 根源分析 

分 类 号：X928[环境科学与工程—安全科学]