化學品輸送及製程安全事件調查方法之改進研究

Abstract

本研究期望找到有效與全面的製程安全事件(故)調查方法。，協助事 業單位能有效地進行製程安全事件(故)調查，支持管理階層發掘根本原 因。 研讀我國事故調查訓練教材與法規、CCPS化學製程事故調查指引 與CSB事故調查報告，理解事故調查的架構與執行困難。本研究發展獨 特的6M文件證據檢核表與辨識關鍵事件環，並引用CSB AcciMap事故 圖。6M文件證據檢核表利於蒐集、登錄與追蹤證據，並有助於發展 AcciMap。辨識關鍵事件環有效協助調查人員進行後續根本原因分析作 業，減少作業發散與耗費過多資源。AcciMap事故圖指出於公司、工業與 政府的較高層事故原因。最後以強化安全衛生管理系統為目的，營造安 全文化的環境，循環至製程安全事件(故)調查的起始 – 事件(故)通報， 事業單位全員以自身安全為歸依，關注作業場所任何變化與可能危害。 藉國內實際案例驗證此調查方法的有效性與局限性，提出研究的結 論與對現行調查方法的建議。 關鍵字：製程安全事件(故)調查方法、6M 文件證據檢核表、辨識關鍵事 件環、AcciMap 事故圖、根本原因分析、安全衛生管理系統

The purpose of this study was to find out an efficient & comprehensive investigation methodology of process safety incident (accident) investigation. It can be used to effectively assist the company incident investigation process, to support the management to dig out the root cause. Studying Taiwan accident investigation training materials and regulations, CCPS “Guidelines for Investigating Chemical Process Incidents” and CSB investigation reports to understand the structure of accident investigation and the difficulties. This study develops the unique 6M documentary evidence checklist and the key events identification ring, and introducing CSB AcciMap. The 6M documentary evidence checklist facilitates to collect, log and trace the evidences, and it is helpful to develop the AcciMap. The key events Identification ring can effectively assisted the investigators to progress the root cause analysis jobs, reducing jobs divergence and consume too many resources. AcciMap addresses the root causes, noted in the company, industry and government levels. The final purpose is enhancing the safety and health management system to creating a safety culture atmosphere, then return to the initial of the process safety event investigation — incident (accident)notification, all persons concern their own safety and aware any change and possible hazards in the workplace. The study took Taiwan incident cases to verify the ffectiveness and limitation of the proposed process safety event investigation method, listing the study conclusion and the recommendations of current investigation method. Keywords: process safety incident (accident) investigation method, 6M documentary evidence checklist, key events identification ring, AcciMap, root cause analysis, safety and health management system