問題解決模式應用於事故調查之研究

Abstract

本研究主要是藉由輸入-流程-輸出(Input-Process-Output)系統概念依循規劃(Plan)、執行(Do)、查核(Check)與矯正(Check)的PDCA流程，輔以企業解決產品異常及製程問題的解決手法為架構，將相同邏輯的意外事故原因方法論的優點及特色加以歸納整合列入探討，在此運作之下，循序漸進協助事業單位建立系統性、一致性、通用性及可重複性的事故調查模式，並依有效性及可行性擬定改善方案，提供事業單位日後分析、改善及風險管理的參考，在各個階段中反映問題解決嚴謹的思考邏輯及其各階段任務中所需達成的目標，它不僅提供系統化循序漸進解決問題的運作機制並可建立起事業單位內各組織及人員共同的語言，可使得事業單位事故調查管理品質提昇，建置標準化的調查模式，進而達到零缺點要求。 此外，本研究係以高科技廠事件案例，進行實際案例驗證及分析探討，證明建置此意外事故調查模式對事業單位運作是正面的幫助，期盼應用問題解決模式讓事業單位人員易於學習及使用，最後將事故調查經驗藉由知識管理運作機制轉化為有價值的知識庫，此機制營造出來的價值，有效加以整合及儲存在面對同樣問題時可依循參考外亦可作為公司永久的資產，有助於事業單位內部自主管理避免意外事故發生。

The purpose of study is to sum up and explore the advantages and features of accident cause methodologies of the same logic through input-process-output system concept, following the process of PDCA (Plan, Do, Check and Act), and based on the framework of business' method of solving product anomalies and process problems to help business units establish a systematical, consistent, universal and repeatable accident investigation model and formulate improvement plans based on effectiveness and feasibility for businesses' reference for their later analysis, improvement work and risk management. Through the reflection of rigorous problem-solving logic and the goals achieved in each stage, it can not only provide a systematical, step-by-step problem-solving mechanism but also establish a common language for the organizations and personnel within a business unit, which can lead to the boost of accident investigation quality and the establishment of standardized investigation model, further to meet zero-flaw requirement. The accident cases of high-tech manufacturers were used in this study to conduct case verification and analysis. It proved that accident cause investigation model can positively contribute to the operation of business units. It is hoped that personnel in each business unit can learn to apply problem-solving model and turn their experience with accident cause investigation into valuable knowledge through a knowledge management and operation mechanism, and the value created by this mechanism can also be effectively integrated and stored as companies' permanent assets for their reference when encountering the same problems in the future, which is helpful to business units' autonomy and the prevention of accidents.