基于安全文化建设的石化企业未遂事件管理研究
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摘要
在重大事故发生之前,往往会出现许多较小的未造成伤害和损失的事件,即未遂事件。传统的安全管理方式大多以强调已发生的事故为管理对象,忽略了大量的未遂事件,是一种被动的、事后型的管理方法,很难做到防患于未然,而对未遂事件进行科学管理,是在事故发生前采取措施,是一种主动预防型的管理方法。
未遂事件管理是以事故预防为主,主动反应、积极控制的“问题发现型”安全管理模式,符合当前主流的系统安全管理方法的要求。本文综述了国内外未遂事件管理研究的进展与现状,分析了未遂事件的致因模型和未遂事件管理在实施过程中的潜在问题。未遂事件管理在国内不能有效实施的主要原因是员工主动参与安全管理的意识薄弱,传统的安全管理方法以强制性管理为主,不能激发员工参与安全管理的积极主动性,使员工形成了被动接受的习惯。安全文化建设是以提升员工的安全意识为主,倡导员工主动参与、全员参与的预防型安全管理。安全文化主动预防性的理念与未遂事件管理的理念相吻合,因此,从安全文化建设的角度采取措施可以更好地解决未遂事件管理的潜在问题,促进未遂事件管理的有效实施。
结合国内某大型石化企业烯烃厂安全管理的具体情况,本研究以安全文化建设为出发点,研究设计了一套未遂事件管理方法,以开发的未遂事件管理软件平台为工具,在该企业进行了未遂事件管理的实践与研究。结合安全文化建设,采取了“说出心里话、安全五分钟和HSE观察”三种措施,提升了员工积极参与未遂事件管理的意识,提高了未遂事件报告率,保障了未遂事件管理系统的顺利实施。未遂事件管理系统通过2009年的实施,收集了大量数据,通过提取关键信息,对导致未遂事件发生的人的不安全行为和物的不安全状态进行归纳和总结,得出未遂事件直接原因、间接原因和烯烃厂管理体系要素之间的关系,据此建立了未遂事件原因分析模型。同时,根据数据样本的特点,选取灰色关联度分析方法,进行深入的量化分析,通过对引发未遂事件的各种直接原因的发生概率和后果严重度的分析,辨识这些原因的事故风险;另外,灰色关联度的预测方法为未遂事件管理提供了一个新的思路。
Before a serious or catastrophic accident happens usually, there would be numerous minor incidents caused no loss or damage, which are called near miss. The traditional safety management focuses on accident rather than near miss, which is a passive measure and would not prevent accidents from occuring. The near miss management is proactive prevention that takes measures before accidents happen.
Near miss management focuses on accident prevention, which is a proactive means and emphasizes on finding problems before an accident happens. The near miss management meets the needs of the modern system safety management. This work summarises the historic development of near miss research, and analyzes the near miss causation and the potential difficulties met in practice. The main reason that the current near miss management has not been successful is due to the employees being not actively involved in the management. The traditional safety management is hard to motivate the employees participating in safety management, and employees have a passive habit on the management. The main purpose of safety culture program is to improve safety consciousness, and to encourage all employees to take part in safety management voluntarily. The idea of safety culture is identical with that of near miss management, and the measures based on safety culture can be more useful to solve the potential problems of near niss nanagement.
With a selected Olefine Plant in a large petrochemical company, the near miss management system for it has been studied based on safety culture and a software program for the management system has been developed. The measures based on safety culture are formulated to improve employees’safety consciousness for near miss management. The near miss reports of the plant in the year 2009 was analysed, and the correlations among the direct causes of near miss, the indirect causes of near miss and Olefine Plant management system elements were derived, and also a near miss cause analysis model was developed. Meanwhile, according to the characteristics of the sample, the Grey Relational Analysis was used for the further study, which identified accident risk of the direct causes of near miss by probability and consequence severity analysis, providing a new idea for near miss management by Grey Relation Analysis prediction.
未遂事件管理是以事故预防为主,主动反应、积极控制的“问题发现型”安全管理模式,符合当前主流的系统安全管理方法的要求。本文综述了国内外未遂事件管理研究的进展与现状,分析了未遂事件的致因模型和未遂事件管理在实施过程中的潜在问题。未遂事件管理在国内不能有效实施的主要原因是员工主动参与安全管理的意识薄弱,传统的安全管理方法以强制性管理为主,不能激发员工参与安全管理的积极主动性,使员工形成了被动接受的习惯。安全文化建设是以提升员工的安全意识为主,倡导员工主动参与、全员参与的预防型安全管理。安全文化主动预防性的理念与未遂事件管理的理念相吻合,因此,从安全文化建设的角度采取措施可以更好地解决未遂事件管理的潜在问题,促进未遂事件管理的有效实施。
结合国内某大型石化企业烯烃厂安全管理的具体情况,本研究以安全文化建设为出发点,研究设计了一套未遂事件管理方法,以开发的未遂事件管理软件平台为工具,在该企业进行了未遂事件管理的实践与研究。结合安全文化建设,采取了“说出心里话、安全五分钟和HSE观察”三种措施,提升了员工积极参与未遂事件管理的意识,提高了未遂事件报告率,保障了未遂事件管理系统的顺利实施。未遂事件管理系统通过2009年的实施,收集了大量数据,通过提取关键信息,对导致未遂事件发生的人的不安全行为和物的不安全状态进行归纳和总结,得出未遂事件直接原因、间接原因和烯烃厂管理体系要素之间的关系,据此建立了未遂事件原因分析模型。同时,根据数据样本的特点,选取灰色关联度分析方法,进行深入的量化分析,通过对引发未遂事件的各种直接原因的发生概率和后果严重度的分析,辨识这些原因的事故风险;另外,灰色关联度的预测方法为未遂事件管理提供了一个新的思路。
Before a serious or catastrophic accident happens usually, there would be numerous minor incidents caused no loss or damage, which are called near miss. The traditional safety management focuses on accident rather than near miss, which is a passive measure and would not prevent accidents from occuring. The near miss management is proactive prevention that takes measures before accidents happen.
Near miss management focuses on accident prevention, which is a proactive means and emphasizes on finding problems before an accident happens. The near miss management meets the needs of the modern system safety management. This work summarises the historic development of near miss research, and analyzes the near miss causation and the potential difficulties met in practice. The main reason that the current near miss management has not been successful is due to the employees being not actively involved in the management. The traditional safety management is hard to motivate the employees participating in safety management, and employees have a passive habit on the management. The main purpose of safety culture program is to improve safety consciousness, and to encourage all employees to take part in safety management voluntarily. The idea of safety culture is identical with that of near miss management, and the measures based on safety culture can be more useful to solve the potential problems of near niss nanagement.
With a selected Olefine Plant in a large petrochemical company, the near miss management system for it has been studied based on safety culture and a software program for the management system has been developed. The measures based on safety culture are formulated to improve employees’safety consciousness for near miss management. The near miss reports of the plant in the year 2009 was analysed, and the correlations among the direct causes of near miss, the indirect causes of near miss and Olefine Plant management system elements were derived, and also a near miss cause analysis model was developed. Meanwhile, according to the characteristics of the sample, the Grey Relational Analysis was used for the further study, which identified accident risk of the direct causes of near miss by probability and consequence severity analysis, providing a new idea for near miss management by Grey Relation Analysis prediction.
引文
[1]胡云孙广慧闵春新,应重视未遂事故的统计与管理,职业安全,2003.2:65
[2]袁大祥严四海,事故的突变论,中国安全科学学报,2003.10(3):5~7
[3]霍志勤,调查结果必须真实可靠——关于改进不安全事件调查工作的调研报告,空中交通管理,2003.第147期:52~53
[4] Schaaf T.W.Van der,Near Miss Reporting in the chemical process industry,Microelectron Reliab,1995.35(9-10):1233~1243
[5]金龙哲宋存义主编,安全科学原理,北京:化学工业出版社,2004.7~12
[6]钟茂华温丽敏刘铁民,关于危险源分类与分级探讨,中国安全科学学报,2003.13(6):18~20
[7] Simon Jones, Christian Kirchsteiger, Willy Bjerke,The importance of near miss reporint to further improve safety performance,Jounal of loss prevention in the process industries,1999.12:59~67
[8] U.RITWIK ,Risk–based approach to near miss,KUWAIT hydrocarbon processing,2002.10:14~16
[9] Wright,Advanced Aviation Safety and Aircraft Accident and Incident Investigation Course,Joint Air Traffic Services,2003.8:23~26
[10] James R. Phimister, Ulku Oktem, etc.,Near-Miss incident management in the chemical process industry,Risk Analysis,2003.23(3):445~460
[11]张晓,Near Miss管理分析及其在某公司的管理研究,[学位论文]北京:中国地质大学(北京),2007
[12] Santos Reyes, Alan N. Beard,Assessing safety management systems, Journal of Loss Prevention in Process Industries,2002.15:77~95
[13]秦凤竹,美国化工行业未遂事件管理,安全、健康和环境,2007.7(7):2~3
[14]贺兴容,供电企业安全文化的构建及评价,[学位论文]成都:西南交通大学,2006:2~3
[15] Rune Berentsen, Rolf H. Holmboe, Incidents/accidents classification and reporting in Stateoil, Journal of Hazardous Materials,2004.111:155~159
[16]罗云编著,现代企业安全管理,北京:化学工业出版社,2002.1~8
[17]张晓华张岩姜学艳,未遂事件管理,安全、健康与环境,2007.7(10):8~19
[18] Linda B. Wright, GA Utrecht, etc.,The use of near miss information in the railway industry: a case study in the Netherlands,ACM International Conference Proceeding Series,Chania, Greece,2005.132:51~56
[19] the Institute of Management & Administration, Disaster prevention: How to learn from near misses,Anonymous Contractor’s Business Management, 2000.10
[20] Davies, J.B., Wright, L., Courtney, E., and Reid H.,Confidential incident reporting on the UK railways: The‘CIRAS’System,Cognition, Technology, and Work,2000.2:117~125
[21] Tjerk van der Schaaf, Lisette Kanse,Biases in incident reporting databases: an empirical study in the chemical process industry,Safety Science,2004(42):57~67
[22] Reason,Safety culture: Some theoretical and practical issues,Work and Stress,1998.12 (3):293-310
[23] T. Lee, K. Harrison,Assessing safety culture in nuclear power stations, Safety Science,2000.42:61~97
[24]裴智东,安全发展思路与实践,北京:石油工业出版社,2006.13~14
[25]马尚权颜烨,安全文化缘起及国内安全文化研究建设现状,西北农林科技大学学报,2007.7(4):120~127
[26]高寅欣,电力行业企业文化测评研究,[学位论文]北京:北京交通大学,2008.15~17
[27]陈坤,化工企业安全文化评价指标体系研究,[学位论文]重庆:重庆大学,2007.7~8
[28]栾兴华,化险为夷——企业安全文化建设实务,深圳:海天出版社,2009.100~102
[29]陈红著,煤炭企业重大事故防控的“行为栅栏”研究,北京:经济科学出版社,2008.21~23
[30]徐德蜀邱成编著,企业安全文化简论,北京:化学工业出版社,安全科学与工程出版中心,2005.75~84
[31] Jean-Francois Henri,Organizational culture and performance measurement systems,Organizations and Society,2006.31:77~103
[32]张玉,建筑企业安全文化建设的探讨,[学位论文]重庆:重庆大学,2004.14~15
[33] Alexander Muermann, Ulku Oktem,The near miss management of operational risk,The Journal of Risk Finance,2002.4(1):25~26
[34] CHARSLEY P.,Hazard and risk assessment,DNV Loss Control Management,1999.4:5~10
[35]隋鹏程陈宝智隋旭编著,安全原理,北京:化学工业出版社,2005.34~37
[36]何学秋等编著,安全工程学,徐州:中国矿业大学出版社,2002.81~86
[37] James R. Phimister, Ulku Okem, Paul R. Kleindorfer, etc.,Near miss incident management systems in the chemical process industry,Risk Analysis,2003.23(3):445~459
[38] Hyungjoon Yoon, Hanyong Lee, etc.,Development of a near miss management system to prevent industrial accident,Journal of the Korean Institute of Chemical Engineers,2000.38(2):166~172
[39]栾兴华,化险为夷——企业安全文化建设实务,深圳:海天出版社,2009.134~135
[40]贺兴容,供电企业安全文化的构建及评价,[学位论文]成都:西南交通大学,2006.25~27
[41]邵辉王凯全编,安全心理学,北京:化学工业出版社,2004.50~53
[42]苏哲,中油炼化企业安全生产管理控制系统研究,[学位论文]北京:对外经济贸易大学,2007.37~38
[43] Wiggleworth,Human factors commentary on innovations at rail road-highway grade crossings in Australia,Journal of Safety Research,2001.32:309~321
[44] S.Torp, B.E.Moen,The effects of occupational health and safety management on work environment and health:A prospective study,Applied Ergonomics,2006.26(3):17~19
[45]刘纯,激励理论及其在企业中的应用,经济理论与经济管理,2001.1:35~40
[46] Willie Hammer、Dennis Price, Occupational Safety Management and Engineering,北京:清华大学出版社,2003.37~38
[47]邵辉王凯全编,安全心理学,北京:化学工业出版社,2007.196~206
[48]何学秋等编著,安全工程学,徐州:中国矿业大学出版社,2002.111~121
[49]邓聚龙,灰色论基础,武汉:华中科技大学出版社,2002.158~166
[50]徐国祥主编,统计预测和决策,上海:上海财经大学出版社,2005.202~203
[51]汪元辉主编,安全系统工程,天津:天津大学出版社,2006.16~27
[52]赵保胜田建国张辉,时间序列关联分析的灰色方法,山东师范大学学报,2004.19(4):17~19
[53]彭文菁,灰色趋势关联分析及其应用,[学位论文]武汉:武汉理工大学,2008.24~31
[54]方开泰马长兴,正交与均匀试验设计,北京:科学出版社,2001.46~52
[55] Linda Wright, Tjerk van der Schaaf, Accident versus near miss causation:a critical review of the literature、an empirical test in the UK railway domain、and their implications for other sectors, Journal of Hazardous Materials, 2004.1:105~110
[2]袁大祥严四海,事故的突变论,中国安全科学学报,2003.10(3):5~7
[3]霍志勤,调查结果必须真实可靠——关于改进不安全事件调查工作的调研报告,空中交通管理,2003.第147期:52~53
[4] Schaaf T.W.Van der,Near Miss Reporting in the chemical process industry,Microelectron Reliab,1995.35(9-10):1233~1243
[5]金龙哲宋存义主编,安全科学原理,北京:化学工业出版社,2004.7~12
[6]钟茂华温丽敏刘铁民,关于危险源分类与分级探讨,中国安全科学学报,2003.13(6):18~20
[7] Simon Jones, Christian Kirchsteiger, Willy Bjerke,The importance of near miss reporint to further improve safety performance,Jounal of loss prevention in the process industries,1999.12:59~67
[8] U.RITWIK ,Risk–based approach to near miss,KUWAIT hydrocarbon processing,2002.10:14~16
[9] Wright,Advanced Aviation Safety and Aircraft Accident and Incident Investigation Course,Joint Air Traffic Services,2003.8:23~26
[10] James R. Phimister, Ulku Oktem, etc.,Near-Miss incident management in the chemical process industry,Risk Analysis,2003.23(3):445~460
[11]张晓,Near Miss管理分析及其在某公司的管理研究,[学位论文]北京:中国地质大学(北京),2007
[12] Santos Reyes, Alan N. Beard,Assessing safety management systems, Journal of Loss Prevention in Process Industries,2002.15:77~95
[13]秦凤竹,美国化工行业未遂事件管理,安全、健康和环境,2007.7(7):2~3
[14]贺兴容,供电企业安全文化的构建及评价,[学位论文]成都:西南交通大学,2006:2~3
[15] Rune Berentsen, Rolf H. Holmboe, Incidents/accidents classification and reporting in Stateoil, Journal of Hazardous Materials,2004.111:155~159
[16]罗云编著,现代企业安全管理,北京:化学工业出版社,2002.1~8
[17]张晓华张岩姜学艳,未遂事件管理,安全、健康与环境,2007.7(10):8~19
[18] Linda B. Wright, GA Utrecht, etc.,The use of near miss information in the railway industry: a case study in the Netherlands,ACM International Conference Proceeding Series,Chania, Greece,2005.132:51~56
[19] the Institute of Management & Administration, Disaster prevention: How to learn from near misses,Anonymous Contractor’s Business Management, 2000.10
[20] Davies, J.B., Wright, L., Courtney, E., and Reid H.,Confidential incident reporting on the UK railways: The‘CIRAS’System,Cognition, Technology, and Work,2000.2:117~125
[21] Tjerk van der Schaaf, Lisette Kanse,Biases in incident reporting databases: an empirical study in the chemical process industry,Safety Science,2004(42):57~67
[22] Reason,Safety culture: Some theoretical and practical issues,Work and Stress,1998.12 (3):293-310
[23] T. Lee, K. Harrison,Assessing safety culture in nuclear power stations, Safety Science,2000.42:61~97
[24]裴智东,安全发展思路与实践,北京:石油工业出版社,2006.13~14
[25]马尚权颜烨,安全文化缘起及国内安全文化研究建设现状,西北农林科技大学学报,2007.7(4):120~127
[26]高寅欣,电力行业企业文化测评研究,[学位论文]北京:北京交通大学,2008.15~17
[27]陈坤,化工企业安全文化评价指标体系研究,[学位论文]重庆:重庆大学,2007.7~8
[28]栾兴华,化险为夷——企业安全文化建设实务,深圳:海天出版社,2009.100~102
[29]陈红著,煤炭企业重大事故防控的“行为栅栏”研究,北京:经济科学出版社,2008.21~23
[30]徐德蜀邱成编著,企业安全文化简论,北京:化学工业出版社,安全科学与工程出版中心,2005.75~84
[31] Jean-Francois Henri,Organizational culture and performance measurement systems,Organizations and Society,2006.31:77~103
[32]张玉,建筑企业安全文化建设的探讨,[学位论文]重庆:重庆大学,2004.14~15
[33] Alexander Muermann, Ulku Oktem,The near miss management of operational risk,The Journal of Risk Finance,2002.4(1):25~26
[34] CHARSLEY P.,Hazard and risk assessment,DNV Loss Control Management,1999.4:5~10
[35]隋鹏程陈宝智隋旭编著,安全原理,北京:化学工业出版社,2005.34~37
[36]何学秋等编著,安全工程学,徐州:中国矿业大学出版社,2002.81~86
[37] James R. Phimister, Ulku Okem, Paul R. Kleindorfer, etc.,Near miss incident management systems in the chemical process industry,Risk Analysis,2003.23(3):445~459
[38] Hyungjoon Yoon, Hanyong Lee, etc.,Development of a near miss management system to prevent industrial accident,Journal of the Korean Institute of Chemical Engineers,2000.38(2):166~172
[39]栾兴华,化险为夷——企业安全文化建设实务,深圳:海天出版社,2009.134~135
[40]贺兴容,供电企业安全文化的构建及评价,[学位论文]成都:西南交通大学,2006.25~27
[41]邵辉王凯全编,安全心理学,北京:化学工业出版社,2004.50~53
[42]苏哲,中油炼化企业安全生产管理控制系统研究,[学位论文]北京:对外经济贸易大学,2007.37~38
[43] Wiggleworth,Human factors commentary on innovations at rail road-highway grade crossings in Australia,Journal of Safety Research,2001.32:309~321
[44] S.Torp, B.E.Moen,The effects of occupational health and safety management on work environment and health:A prospective study,Applied Ergonomics,2006.26(3):17~19
[45]刘纯,激励理论及其在企业中的应用,经济理论与经济管理,2001.1:35~40
[46] Willie Hammer、Dennis Price, Occupational Safety Management and Engineering,北京:清华大学出版社,2003.37~38
[47]邵辉王凯全编,安全心理学,北京:化学工业出版社,2007.196~206
[48]何学秋等编著,安全工程学,徐州:中国矿业大学出版社,2002.111~121
[49]邓聚龙,灰色论基础,武汉:华中科技大学出版社,2002.158~166
[50]徐国祥主编,统计预测和决策,上海:上海财经大学出版社,2005.202~203
[51]汪元辉主编,安全系统工程,天津:天津大学出版社,2006.16~27
[52]赵保胜田建国张辉,时间序列关联分析的灰色方法,山东师范大学学报,2004.19(4):17~19
[53]彭文菁,灰色趋势关联分析及其应用,[学位论文]武汉:武汉理工大学,2008.24~31
[54]方开泰马长兴,正交与均匀试验设计,北京:科学出版社,2001.46~52
[55] Linda Wright, Tjerk van der Schaaf, Accident versus near miss causation:a critical review of the literature、an empirical test in the UK railway domain、and their implications for other sectors, Journal of Hazardous Materials, 2004.1:105~110