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    题名: 職業傷害事故調查方法;Occupation Incident Investigation Technique
    作者: 姚佩伶;Pei-ling Yao
    贡献者: 環境工程研究所
    关键词: 系統化原因分析技術;根本原因分析;職業傷害;事件及狀態因子分析;Root Cause Analysis;Systematic Cause Analysis Technique;Events and Conditional Factors Analysis;Occupational Incident
    日期: 2009-07-11
    上传时间: 2009-09-21 12:19:35 (UTC+8)
    出版者: 國立中央大學圖書館
    摘要: 職業傷害事故往往造成人員傷亡、財物損失和事業單位聲譽受損,事故調查至今雖已有數種不同的方法和技術,但仍無法有效降低事故發生的頻率,主要原因為事故調查多仰賴專家經驗,而事業單位普遍缺乏專業的調查人員,因此無法有效執行調查作業、鑑定事故發生的根本原因。國內勞檢單位雖有事故調查的專責人員,但由於國內工廠數為數眾多,調查人力不足,通常只能針對重大事故進行調查。有鑒於此,事業單位必須培訓專責的調查人員,學習適當的事故調查方法,一旦事故發生後,即可立即進行蒐證作業、分析事故原因及探討管理系統的不足之處,對於系統缺失必須對症下藥採取矯正措施,才能避免相同或類似的事故一再發生,也可確保員工在安全的工作環境下作業。 事故調查應分為製程安工事故與職業傷害兩類,由於重大工安事故頻率甚低、涉及層面較廣,調查小組通常需要各領域的專業人員,並不是一般人員能力所及,反之,職業傷害發生頻率高,事故原因涉及層面較為單純,事業單位內部受過基本事故調查訓練的人員即可勝任。但常見的事故調查方法並未特別區分工安事故或職業傷害,因此本研究以職業傷害事故調查為重點,發展一套適用於一般事業單位的事故調查方法,以OSHA 4Ps模式將證據有效分為四類後,利用ECFA+的方法繪製時間序列,並採用SCAT查核表與設計RCS判斷事故原因,最後連結至OHSAS 18001系統功能,以利辨識管理系統的不足之處。 Reporting of and investigating adverse events such as accidents and incidents are critical in identifying risk control failures and fulfilling regulatory requirements. The main objective of accident investigation is not to place blame on the individual or individuals involved but to understand the root causes of the accident 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 any organization pursuing excellent safety and health management. There have been active discussions among the safety professionals on the distinctions between process safety and personal safety after the PB Texas City accident. It has been commonly accepted that personal safety performance cannot be used to measure the success of process safety management and vice versa. It is based on this principle that different investigation techniques should be developed for process accidents and occupational or personal injury accidents. The former focuses on low-frequency and high-consequence mishaps while the latter targets common workplace injury cases and near misses. A systems approach to occupational incident investigation is proposed in this study. The methodology is primarily consisted of information collection, analysis of the conditions and events leading to the incident, and root cause analysis. US OSHA’s 4Ps method for collecting information relevant to people, parts, position, and paper is adopted to find the facts about an accident. ECFA+, the modified events and conditional factors analysis technique, is used to re-construct the sequence of events leading to the accident. Since the primary target of the investigation is occupational accident, the International Loss Control Institute’s Systematic Cause Analysis Technique is utilized to analyze the root causes of an accident. An attempt to treat risk control measures as part of the root causes of an accident is presented in this study. It is hoped that the proposed technique will provide practical solutions to occupational incident investigation.
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