安全生产事故往往由多组织交互、多因素耦合造成,事故原因涉及多个组织.为预防和遏制多组织生产安全事故的发生,基于系统理论事故建模与过程模型(Systems-Theory Accident Modeling and Process,STAMP)、24Model,构建一种用于多组织事故分析的方法,并以青岛石油爆炸事故为例进行事故原因分析.结果显示:STAMP-24Model可以分组织,分层次且有效、全面、详细地分析涉及多个组织的事故原因,探究多组织之间的交互关系;对事故进行动态演化分析,可得到各组织不安全动作耦合关系与形成的事故失效链及管控失效路径,进而为预防多组织事故提供思路和参考.
Analysis of multi-organization accident based on STAMP-24Model
The purpose of this paper is to prevent and curb multi-organization production safety accidents.To achieve this goal,we used STAMP-24Model to analyze the causes of multi-organization accidents,dynamically demonstrated the dynamic evolution process of accidents based on unsafe behaviors,and found the failure chain and out-of-control path of accidents.In the process of research,we took the Qingdao oil explosion accident as the research object.First of all,we used the analysis mechanism of the STAMP model and behavioral safety 24Model to construct the accident analysis process and action mechanism diagram and combined it with the accident investigation report to identify the key nodes of accident evolution and related events.Then,through the principle of 24Model,we obtained 12 unsafe actions of 3 enterprise organizations,and on this basis,derived 8 types of safety capability problems,13 missing safety management systems,and 16 missing safety cultures corresponding to the 12 unsafe actions.Besides,we obtained 13 failure constraints and 19 inappropriate decision-making or control behaviors of 7 regulatory organizations by using the STAMP model principle.In addition,the interaction relationship of various organizations is obtained through the dynamic evolution analysis of accidents,and the coupling relationship of unsafe actions of various organizations is analyzed from the perspective of behavioral safety.37 failure chains formed by unsafe behaviors of multi-organizations and 3 control failure paths are obtained,and two barriers are proposed to prevent accidents.The results show that the STAMP-24 Model combines the advantages of the two models'analysis mechanisms,and can identify the causes of accidents in multiple organizations in a comprehensive and detailed way.It can also dynamically show the process of accidents,and explain the coupling effect of unsafe actions in various organizations from the perspective of behavioral safety.
safety engineeringSystems-Theory Accident Modeling and Process(STAMP)24Modelmulti-organization accidentscause analysis
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