事故調查與分析方法之應用

The Applications of Incident Investigation and Analysis Method

張承明(Cheng-Ming Chang) ； 于樹偉(Shuh-Woei Yu) ； 張日誠(Ri-Cheng Chang)

《勞工安全衛生研究季刊》 21卷1期 (2013/03) Pp. 86-106

摘要

事故調查主要目的為了解事故發生的真相，進而改善風險控制與管理系統缺失，避免相同、類似的災害再度發生，而非著重於責任歸屬或懲處員工。事故調查常犯的錯誤是只調查事故的表面原因，並未深入調查管理系統失效，儘管勞工安全衛生法第28條與勞動檢查法第27條，已經在我國執行多年，但事業單位仍普遍缺乏有效的意外事故調查方法，成為預防個人傷害和工安事故的主要障礙。本研究參酌先進國家事故調查訓練教材和實施方法，擬訂我國事故調查訓練教材，目的在於協助事業單位建立事故調查標準作業流程。主要參考美國OSHA訓練教材，執行系統化事故資料收集與評估資料完整性，並彙整英國HSE事故調查指引，分析事故的基本原因。以提供國內勞檢機構與政府機關參考與借鏡。

關鍵字

事故調查 ； 根本原因分析 ； 事故資料管理

並列摘要

The main objective of accident investigation is not to place blames on the individuals involved but to understand the root causes so that effective controls can be put in place to prevent the occurrence of the same or similar accidents. It has been advocated by many experts that accident investigation is an essential learning process for organizations pursuing excellent safety and health management. The systems approach to incident investigation proposed in this study is consisted of information collection, analysis of the conditions and events leading to the incident, and root cause analysis. OSHA Training Institute's accident investigation training course materials and HSG 245 of the UK are adopted as the building blocks for the proposed incident investigation model. It is hoped that the proposed methodology and training courses will lead to effective incident investigation by both private organizations and the official inspectors.

並列關鍵字

Incident investigation ； Root cause analysis ； Incident information management

參考文獻

行政院勞委會。勞工安全衛生法。http://laws.cla.gov.tw/；2008。

Livingston, A.D.,Priestley, K.(2001).Root causes analysis: Literature review.Britain:HSE.

(Department of Energy. Implementation Guide For Use With DOE Order 225.1A. Accident Investigations (USA); 1997.).

Snorre, S.(2002).Methods for accident investigation.Norwegian:Norwegian University of Science and Technology.

Hollnagel, E.(2004).Barriers and Accident Prevention.Burlington:Ashgate Publishing Limited.