为应对大量使用数字组件和构建复杂系统所带来的安全挑战，将系统工程的思想融入事故预防被认为是有效的应对方法.Systems-theoretic accident model and processes（STAMP）正是一种基于系统论的事故分析模型，目前已在航空航天、化工、医疗、交通安全等领域取得良好的应用.本文首次尝试使用STAMP模型详细分析一起煤矿事故，分别从物理过程、基层操作、直接监管、矿级监管和系统设计、省级监管及事故的动态过程等方面对导致事故发生的控制缺陷进行剖析，发现除技术原因和工人违章操作外，自下而上有12个组织机构存在控制错误，导致这些错误的关键原因是该系统分层控制结构中各层之间的反馈回路在系统外部环境改变后发生了变化.总之，煤矿事故是我国第一大生产事故，本文希望能提供一个更系统、广泛的视角，以帮助发现日益复杂的煤矿系统存在的安全隐患，减少类似事故发生的可能性.
Abstract
The ever-increasing amount of digital components and the ever more complex systems have brought more challenges to safety. It's thus believed that systems theory once being implied into accidents prevention, will serve as an effective way to understand accident causation. Systems-theoretic accident model and processes (STAMP) is an accident model based upon systems theory, and has been widely applied to fields such as astronomy, chemical industry, medical services and transportation safety. This paper attempts to use the STAMP model to a coal mine for the first time, and analyzes the control flaws leading the accidents in the dimension of physical progress, first-level operation, direct regulatory agencies, company supervisory and system design, provincial government, and dynamics process. Results show that apart from technical reasons and the rule-breaking behaviors from the coal mine workers, there have been controlling mistakes in 12 organizational structures, resulting mainly from the changes of the feedbacks in different layers of the multiple-layer control structures after the shifts of the outside environment. All in all, given that coal mine accidents take up a large percentage of production accidents in China, we hope that the paper will provide a more systematic and comprehensive view on spotting ever more complex hazards so as to prevent future accidents.
关键词
系统思考 /
煤矿事故 /
原因分析 /
安全约束 /
systems-theoretic accident model and processes (STAMP)
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Key words
system thinking /
coal mine accident /
accident analysis /
safety constraint /
systems-theoretic accident model and processes (STAMP)
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中图分类号：
X921
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参考文献
[1] Ackoff R L. Towards a system of systems concepts[J]. Management Science, 1971, 17(11):661-671.
[2] Leveson N. A new accident model for engineering safer systems[J]. Safety Science, 2004, 42(4):237-270.
[3] Leveson N. Controveries in science and technology volume 2:Technical and managerial factors in the NASA challenger and columbia losses:Looking forward to the future[M]. New York:Mary Ann Liebert Press, 2008.
[4] Ishimatsu T, Leveson N G, Thomas J P, et al. Hazard analysis of complex spacecraft using systems-theoretic process analysis[J]. Journal of Spacecraft and Rockets, 2014, 51(2):509-522.
[5] Leveson N G. Applying systems thinking to aviation psychology[J]. Advances in Aviation Psychology, 2016, 1:17.
[6] Fleming C H, Spencer M, Thomas J, et al. Safety assurance in NextGen and complex transportation systems[J]. Safety Science, 2013, 55:173-187.
[7] Dekker S W A, Leveson N G. The systems approach to medicine:Controversy and misconceptions[J]. BMJ quality & safety, 2014:bmjqs-2014-003106.
[8] Leveson N, Samost A, Dekker S, et al. A systems approach to analyzing and preventing hospital adverse events[J]. Journal of Patient Safety, 2016, 0(0):1-5.
[9] Leveson N, Couturier M, Thomas J, et al. Applying system engineering to pharmaceutical safety[J]. Journal of Healthcare Engineering, 2012, 3(3):391-414.
[10] Leveson N, Daouk M, Dulac N, et al. A systems theoretic approach to safety engineering[R]. Department of Aeronautics and Astronautics, Massachusetts Institute of Technology, Cambridge, 2003.
[11] Grabowski M, Ayyalasomayajula P, Merrick J, et al. Leading indicators of safety in virtual organizations[J]. Safety Science, 2007, 45(10):1013-1043.
[12] Dong A. Application of CAST and STPA to railroad safety in China[D]. Cambridge:Massachusetts Institute of Technology, 2012.
[13] Leveson N G. Applying systems thinking to analyze and learn from events[J]. Safety Science, 2011, 49(1):55-64.
[14] Leveson N. Engineering a safer world:Applying systems thinking to safety[M]. Cambridge:MIT Press, 2012.
[15] 国家安全生产监督管理总局. 辽宁省阜新矿业(集团)有限责任公司孙家湾煤矿海州立井"2.14"特别重大瓦斯爆炸事故调查报告[EB/OL]. (2005-5-13)[2016-7-24]. http://www.chinasafety.gov.cn/zhengwugongkai/2005-05/13/content_140400.htm. State Administration of Work Safety. Liaoning Province Fuxin mining (Group) Co., Ltd. Haizhou Shafts of Sunjiawan coal mine "2.14" major gas explosion accident investigation report[EB/OL]. (2005-5-13)[2016-7-24]. http://www.chinasafety.gov.cn/zhengwugongkai/2005-05/13/content_140400.htm.
[16] Placke M S. Application of STPA to the integration of multiple control systems:A case study and new approach[D]. Cambridge:Massachusetts Institute of Technology, 2014.
[17] 王艾伦, 张营营, 殷杰. 基于功能/结构相似性的复杂系统相似准则研究[J]. 系统工程理论与实践, 2015, 35(12):3225-3232.Wang A L, Zhang Y Y, Yin J. Research on similarity criterion of complex systems based on functional and structural similarity[J]. Systems Engineering-Theory & Practice, 2015, 35(12):3225-3232.
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脚注
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基金
国家自然科学基金（51534008）
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