以人因工程角度分析火災原因─以高雄市為例

火災毀壞物質財產，大量消耗社會資源，也對人民的生命造成威脅。火災發生原因種類多樣，可將其概分為人為因素、設備因素、環境因素等。依據內政部消防署統計，建築物火災長年佔據火災類型首位，因此本研究以高雄市的建築物火災案件做為分析對象，並選用了「人為失誤」、「人為縱火」、「遺留火種」、「電氣因素」等四種發生率最高的起火原因型態，藉由根本原因分析方法：特性要因圖、CCPS分析表等工具，依序分析與探討其顯著致災因素，欲找出在人為因素上造成建築物火災發生之根本原因，並提出改善與預防建議。研究結果發現，「人為縱火」此型態火災較為特殊，縱火動機涉及縱火犯生活環境、情緒、心理等充滿不確定性的個人狀態，牽涉的層面廣泛，無法明確定義其根本原因；在「人為失誤」、「遺留火種」、「電氣因素」等型態火災中，可以發現大部分皆與人為因素存在直接關係。民眾對於防災意識薄弱，常見的情況如家中無配置消防與警報設備、在逃生出口前堆放雜物、未確認所點燃明火是否完全熄滅，或未定期檢驗屋中電器用品是否符合標準等人員不安全行為，使自身處於不安全的環境中卻不自知。本研究以CCPS原因分析表所建立的事故原因分類，大部分造成火災發生及火災擴大的因子為「不當的人員訓練和行為」和「缺乏事故分析與預防」，建議未來若能提升民眾的防災意識與危害認知，則能大大降低火災發生的機率及火災對民眾生命財產的威脅。

關鍵字

建築物火災；根本原因分析；人為因素

並列摘要

Fire disaster consumes a lot of social resources, destroys material property, and also poses a certain degree of threat to people's lives. The causes of fires are diverse and can be categorized as human factors, equipment factors, and environmental factors. According to the statistics of the National Fire Agency, MOI, Building fire disasters have long been the most common type of fires. In order to find out the root causes of fires in buildings caused by human factors, and to propose improvement and prevention suggestions, we have used the tools of Root Cause Analysis, such as characteristic factor diagram and CCPS analysis table, to analyze and discuss the significant factors that cause fires. The results of the study show that, except for "human arson" which is a special type of fire, the motive of arson involves the arsonist's living environment, emotions, psychology and other personal states full of uncertainty, involving a wide range of aspects, and it is impossible to define the root cause; among "human error", "left behind fire" and "electrical factors", most of them can be found to be directly related to human factors. People's awareness of disaster prevention is weak. Commonly, people do not know that they are in an unsafe environment because they do not have firefighting and alarm equipment in their homes, they pile miscellaneous items in front of the escape exits, they do not confirm that the open flame is completely extinguished, or they do not regularly check whether the electrical appliances in their houses meet the standards. According to the classification of causes established by the Center for Chemical Process Safety(CCPS), most of the factors that cause the occurrence and expansion of fires are "improper personnel training and behavior" and "lack of accident analysis and prevention". It is suggested that if we can raise the public's awareness of disaster prevention and hazard recognition in the future, we can greatly reduce the chance of fires and the threat of fires to people's lives and properties.