一种基于系统思维的新型事故因果理论及其适用于工作系统的系统化事故分析方法
摘要：重大事故，例如美国挑战者号航天飞机事故、印度博帕尔事故、日本福岛核事故、中国天津港火灾爆炸事故等，在世界各地都有发生。安全科学家一直试图了解这些事故发生的原因以及如何预防这些事故。事故致因模型和理论构成了许多安全研究领域和实践的基础。尽管已经存在许多事故致因模型，但是还没有一个广泛接受的事故致因模型。本文基于系统理论事故模型和过程（STAMP）和风险管理框架（RMF），提出了一种新的事故因果理论，即危险源-目标系统交互作用理论（简称为ITHTS）。这个理论将人、组织和技术因素统一在同一个同框架中，而且这个理论也将社会因素，如立法、监管和文化因素融入这个框架之中。另一方面，由于ITHTS不能直接应用于事故分析，本文提出了一种基于ITHTS和STAMP的新的工作系统系统事故分析方法（简称为SAAMWS）。以天津港火灾爆炸事故为例，论证了危险源-目标系统交互作用理论的解释力和新的事故分析方法的可行性。但是，在未来还需要做进一步的研究来评估这种新的系统化事故分析方法的可靠性和有效性。
关键词：事故致因模型；风险管理框架；STAMP；安全约束；ITHTS；系统化事故分析法
Title：
A new accident causation theory based on systems thinking and its systemic accident analysis method of work systems
Abstract
Major accidents such as the Space Shuttle Challenger disaster in the USA, the Bhopal Disaster in India, the Fukushima nuclear accident in Japan, and the Tianjin Port fire and explosion accident in China, have occurred all over the world. Safety scientists are always trying to understand why these accidents happened and how to prevent these accidents. Accident models and theories form the basis for many safety research fields and practices. However, there is no universally accepted model with useful elements relating to understanding accident causation, although many accident causation models exist. A new accident causation theory named the Interaction Theory of Hazard-Target System (ITHTS) is proposed based on Systems-Theoretic Accident Model and Processes (STAMP) and Risk Management Framework (RMF), which not only incorporates human, organisational and technological characteristics in the same framework, but also considers the sociological factors such as legislative, regulatory, and cultural factors. On the other hand, a new systemic accident analysis method of work systems (SAAMWS) is proposed based on ITHTS and STAMP because ITHTS cannot be applied directly in accident analysis. We choose Tianjin Port fire and explosion accident as a case study to demonstrate the explanatory power of Interaction Theory of Hazard-target System and the feasibility of the new accident analysis method. Further research needs to be done to assess the reliability and validity of this new systemic accident analysis method.
Keywords：Accident causation model；Risk Management Framework；STAMP；Safety constraint；ITHTS
Systemic accident analysis method
引用格式：
Ge, J., Zhang, Y.Y., Xu, K.L., Li, J.S., Yao, X.W., Wu, C.Y., Li, S.Y., Yan, F., Zhang, J.J., Xu, Q.W. A new accident causation theory based on systems thinking and its systemic accident analysis method of work systems. Process Safety and Environmental Protection, 2022, 158, 644-660.
https://doi.org/10.1016/j.psep.2021.12.036
50天内免费下载地址：https://authors.elsevier.com/a/1eJke3PkfmD9R%7E
备注：
理论创新是一个漫长的过程。这篇文章从草稿到完成用了1年多时间，从投稿到录用经历了8个月，十易其稿。这篇文章提出了ITHTS理论，它是一个基于RMF和STAMP的新的事故致因理论，并在此基础上提出了一种适用于工作系统的新的系统化事故分析方法。
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