消防救災人員依據消防法執行預防火災、搶救災害及緊急救護等三大任務，隨著人口集中及都市化發展，災害搶救之困難度、複雜度及危險性與日俱增；依據內政部消防署統計，自民國99年至103年全台火災件數減少35%，但消防火場救災人員傷亡卻年年增加，由此顯示出消防人員所面臨之危害更加猛烈，而消防人員的救災戰力、裝備器材、安全管理及作戰方式等出現整體管理之系統性問題。 以 James Reason 於1990年所提出之瑞士乳酪理論來檢視消防作業，可以得知任何造成消防搶救人員傷亡之失誤因子其發生僅能視為誘發性失誤 (Active failure)，但誘發性失誤並不是造成消防人員傷亡之主要原因，本篇論文藉由根本原因分析法( Root cause analysis)找出消防人員傷亡之根本原因及系統之潛在性失誤(Latent failure)。
根本原因分析法( Root cause analysis)，是一種回溯性失誤分析工具，本篇將運用此法找出消防人員傷亡之根本原因及系統之潛在性失誤，進而研擬改善方案以避免相關案件再次發生，期許透過本文能使消防救災人員於火場作業時能夠有保障及安全。 ;Firefighters are responsible for fire prevention, disaster rescues, and emergency medical services as regulated in the Fire Services Act. Due to urbanization and population concentration, the levels of difficulty, complexity, and risk of disaster rescues have been escalating. According to the statistics announced by the National Fire Agency under the Ministry of the Interior, the Republic of China, the total number of fires has reduced 35% from 2010 to 2014; however, the firefighter fatalities and injuries have been strangely increasing every year. This contrast shows that the hazards firefighters are confronting are more and more ferocious. Moreover, it indicates that systematic problems of overall management appear in the disaster rescue force, the equipment, safety management and command methods. If one follows the Swiss Cheese Model developed by James Reason in 1990 to review the operation of fire services, one would observe that the model illustrates that any error factor which may cause firefighter fatalities and injuries could be regarded only as active failure. However, such failure is not the major cause of firefighter fatalities and injuries. This study adopts Root Cause Analysis (RCA) and probes into the root causes of the fatalities and injuries and the latent failure in the operation of fire services. Root Cause Analysis is a retrospective method to identify the root causes of problems. This study would investigate the root causes of firefighter fatalities and injuries and the latent failure in the system of fire services with Root Cause Analysis and further propose projects of improvement to prevent similar cases from reoccurrence. We also expect that this research may help enhance the protection and security of firefighters when they work at fire scenes.
