以系統安全管理方法檢核我國軌道運輸之安全—以台鐵站務系統為例

Abstract

「安全」是運輸系統的首要條件，然過於強調「安全第一」的理念，反而減少合理及客觀探究「安全風險」課題的機會。過去軌道運輸系統為提升設施安全標準所須進行之建設投資金額相當龐大，可是事故的發生仍難完全避免。因此，承認運輸活動具有安全風險，並加以系統化管理，在歐洲先進國家已成為主流之作法，此種趨勢值得重視。 本研究首先整理國內外軌道運輸系統發展之現況，再根據各國軌道運輸系統之安全管理機制、與風險危害評估方式，做整理與比較。並進一步將系統安全管理規劃成適合台鐵站務系統現況之研究課題，共分成七個研究課題，包括：系統規劃設計、員工工作環境、零件設備維修、員工教育訓練、資訊傳達聯繫、緊急應變措施、管理監督制度。選用社會心理研究常用之焦點團體法，針對本研究篩選出來的資深台鐵員工進行危害因子之資料蒐集羅列工作，希望藉由資深員工過去的經驗交流與彼此的腦力激盪，可以鉅細靡遺的找出台鐵站務系統所有曾發生過的、以及有發生之可能的事故與危害事件。 針對上述統論整理凝聚之因素，建立台鐵站務系統安全管理檢核問卷，完成初步問卷編製後，聘請台鐵資深主管進行問卷審核之工作，藉由專業人員問卷評估方法，進行安全檢核問卷內容之篩選與修正工作。 接著進行安全檢核問卷進行風險評估工作，透過台鐵站務人員之調查，求得各危害因子量化指標，並利用風險矩陣評估與危險性綜合評估方式，評估各危害因子以及整體系統之危險程度。本研究整理風險矩陣與危險性綜合評估兩個分析之結果，均發現列車無自動門設備、調車場場地之道渣鋪設不平整與水溝加蓋不確實、調車場施工作業零件材料管理放置不當、號誌與通訊線路年久失修難以治本解決、以及旅客坐過站等危害因子之風險較大。 本研究利用系統安全分析方法之FMECA方法，針對各危險因子進行事故失效模式、影響及嚴重度分析。最後藉由焦點團體法與FMECA針對風險指數較高之危險因子進行事故發生原因定性分析，藉由定性分析繪製出五項事故之錯誤樹以及事件樹，以提供台鐵未來在站務系統上針對各個基元事件的改善之道與最佳的防範順序。 關鍵詞：風險、系統安全、風險矩陣評估、危險性綜合評估、錯誤樹、事件樹

In spite of the principle that safety is the first and foremost condition for all railway transportation systems, insisting on supreme-safety extremely will lead to reduce the chance to investigate the safety hazards reasonably and objectively. It is the main stream to admit and recognize that there are hazards in transportation system, and to manage it systematically in the European and American advanced countries. In this study, we discuss seven hazard topics for the stations and switchyards of Taiwan Railway Administration(TRA) referring to System Safety Management conception, including system planning and designing, staff working environment, components and facilities maintenance, staff education and training, information transmission and communication, emergency measurement, management and supervising system. According to the seven hazard topics, we searched and collected hazard factors with the method named Focus Group by discussing with the selected employees of TRA. Basing on the hazard factors we searched, we accomplished a safety-checking survey for the Stations and switchyards of TRA. Before investigation, we invited 25 managers to revise the questions in the safety-checking survey whose reputation is distinguished in TRA. Then we preceded the investigation into the hazard recognition of the stations and switchyards staff of TRA, and we sorted out the degrees of all hazard factors and the whole system by means of Hazard Matrix Assessment and Hazard Synthetic Assessment. After investigation and assessment, we moved on the failure mode, effect, and critical analysis of all hazard factors this study selected on the strength of the method named FMECA, and drew the FTA and ETA to engage in qualitative analysis for the five serious accidents conscientiously. According to FTA and ETA, we could propose the strategy to improve and the optimal prevention-orders for accidents. Keywords: Hazard, System Safety Management, Focus Group, Hazard Matrix Assessment, Hazard Synthetic Assessment, FTA, ETA, FMECA.