Comparative study of systematic analysis on accident causes based on 24Model and accident investigation reports: taking Xiangshui explosion accident as an example

doi:10.16265/j.cnki.issn1003-3033.2022.07.1859

Abstract

Abstract:

In order to promote wide application of 24Model in official accident investigation, and to explore shortcomings of accident investigation reports, with Xiangshui "3·21" explosion accident as an example, accident causes were analyzed based on 24Model, and their action paths were plotted. Then, comparison was made with investigation report. The results show that causes of the accident in Tianjiayi company include unsafe acts, unsafe conditions and lack of safety capability at individual level, as well as lack of safety culture and safety management system at organizational level. In regard of causes at the latter level, the investigation report does not make a detailed analysis, without revealing accident mechanism or accurately defining and dividing various types of responsible persons. However, 24Model, based on complete definition of every cause and factor, is able to summarize the causes with systematic analyses and clarify definition of responsible persons and their liability distribution.

Key words: 24Model, accident cause, system analysis, accident investigation report, Xiangshui explosion accident, comparative study

YUAN Chenhui, SHI Yaqian, MA Yong, ZHAO Yihao, FU Gui. Comparative study of systematic analysis on accident causes based on 24Model and accident investigation reports: taking Xiangshui explosion accident as an example[J]. China Safety Science Journal, 2022, 32(7): 48-55.

Figures/Tables 10

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Safety management system

安全管理体系	具体内容
安全方针D₁	公司原有的安全方针形同虚设,未有效执行安全第一的方针,而是把经济效益放在第一位,为图利润和省时而多次出现违法行为
组织结构D₂	主要负责人和技术团队不具备相应的资质和能力,人员配备不合理;其他部分岗位安全生产责任制与公司实际生产的情况不匹配,随意设置岗位负责人、随意挂名法定代表人
程序文件D₃	D₃₁:未按照《固体废物污染环境防治法》制定正确的危化品贮存管理程序; D₃₂:未按照《国家危险废物名录》、《危险废物鉴别标准》制定针对硝化废料的鉴别、认定及其危险性评估管理程序,未制定巡回检查制度; D₃₃:未有效执行应急知识培训制度; $D 3 4$ :未有效执行法律法规和安全知识培训制度

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编号	动作发出者	具体内容
A₁	硝化车间主任陶某、车间员工	大量堆积贮存硝化废料,且未按规定进行鉴别和认定
A₂	总经理张某、分管工程管理层人员	违法未批先建,擅自开设固废仓库等6项工程
A₃	副总经理杨某、安全总监耿某	刻意瞒报硝化废料有关情况,未及时登记并刻意修改标签和铭牌
A₄	安全科长蒋某及现场安全管理人员	玩忽职守,事故后未采取有效措施,应急响应、人员疏散工作不到位
A₅	安全科现场安全检查人员	仓库安全检查弄虚作假,事故发生前夕安全检查表内容为“正常”

编号	具体内容
B₁	硝化废料成分包含三硝基二酚、间二硝基苯等物质,长期堆积易升温、自燃、爆炸
B₂	旧固废库无机械通风,仅依靠自然通风,通风条件不良
B₃	新固废库存放有焦油等可燃物质

能力因素	具体内容
安全知识C₁	技能知识C₁₁:处理和贮存硝化废料技能缺欠; 理论知识C₁₂:硝化废料燃烧爆炸反应相关知识缺欠,应急救援知识欠缺,仓库通风知识欠缺; 事故经验C₁₃:对事故的严重后果认识不足,事故发生后的应急处置工作经验缺欠
安全意识C₂	法规意识C₂₁:法律意识淡薄,多次出现违法、违规现象; 风险意识C₂₂:风险评估工作无效,突发事件应急准备、响应和救援意识缺欠
安全习惯C₃	习惯性操作C₃₁:员工长期习惯性违规操作,安全检查习惯性弄虚作假; 习惯性指挥C₃₂:管理人员习惯性违规指挥,例如违规指挥未批先建、瞒报谎报等
安全心理C₄	省能心理C₄₁:为避免麻烦图省事而大量堆积储存硝化废料; 侥幸心理C₄₂:对硝化废料存在的危险心存侥幸; 逞能心理、麻痹心理C₄₃:违反法律法规,躲避和对抗有关部门的监督管理

元素号码	安全文化元素	具体内容
E₁	安全的重要度	对安全的重视程度,对我国安全生产方针的理解程度
E₄	安全融入企业管理的程度	安全在组织及个人管理所占比重,对我国“三同时”制度的执行程度
E₅	安全决定于安全意识	发现和处理危险源的能力
E₆	安全的主体责任	将安全当作自己的事情来做,对待安全工作的积极性和负责程度
E₈	安全法规的作用	安全法规是实现安全的必要条件,必须不折不扣地得到遵守和执行
E₉	安全价值观	组织员工对于安全问题的一致性看法
E₁₀	领导的负责程度	组织的管理层以身作则管安全
E₁₁	安全部门的作用	安全部门在组织安全工作上的顾问、协调、组织和咨询作用
E₁₃	安全培训的需求	安全培训、训练在个人层面提高安全能力、减少不安全动作的有效性
E₁₄	部门的安全负责程度	各部门、各子公司各自负责各自的安全,主动做好安全工作
E₁₆	安全管理体系	组织通过安全方针、安全目标、程序文件系统地进行安全管理工作
E₂₁	安全检查的类型	安全检查全面化、系统化、规范化
E₃₀	安全部门的工作	提供高质量的安全顾问、协调、组织和咨询作用
E₃₂	企业应急能力	综合应急预案、专项应急预案和现场处置方案的制定和运行情况