以車諾比爾事故為例探討安全文化之建立

Abstract

本研究之動機在於堅持「君子務本，本立而道生」的精神，探討要建立安全文化的根本原因。 由於「安全文化」這個術語，乃起源於蘇俄車諾比爾核能發電廠的意外事故，所以，要探討安全文化的建立，就必須要以車諾比爾核能發電廠的意外事故為例並加以分析、探討，才能瞭解要建立安全文化制度的真正原因。 經分析、探討車諾比爾事故及其相關文獻而知，車諾比爾事故是源自缺乏安全文化，所以，要確保安全，就必先建立並維護安全文化。有關安全文化的定義應以國際原子能總署（IAEA）之國際核能安全顧問團(INSAG)所提之安全文化的定義為基準，而其他學者的定義僅供參考用，才能不致再次陷入紛亂而無共識的情況。 經文獻探討後，可由此推論：「要建立安全文化以先，要先建立組織及個人均有優先考量安全，以安全為第一或至上的態度」。而建立安全文化之目的，就是要建立組織及個人均有優先考量安全及安全第一或至上的態度。 本論文推論，目前以訪談、問卷調查從事安全文化學術研究的主流，僅是將不同群體對安全事件的態度予以展現，而非推行安全文化之終極目的。若僅是量測公司、企業的安全文化與提出改善方案，而無進一步的實施與檢核，則並非是完整的安全文化研究，僅是紙上空談而已。 因此，本論文提出第一項推動安全文化的建議與對策及新的看法：推行安全文化不可僅於安全文化量測及提出改善方案後就予以停止，應如安全文化PDCA循環圖的步驟，接續執行，否則安全文化將是泡影及空談而無效能。 本論文提出第二項推動安全文化的建議與對策及新的觀念：推行安全文化應如安全文化管理螺旋圖所示，經過多次的安全文化量測及PDCA的循環，並且應以建立「組織及個人均有優先考量安全及安全第一或至上的態度」為軸心，逐漸螺旋向上提昇安全文化。 本論文提出第三項推動安全文化的建議與對策：為推行安全文化，應將INSAG-4安全文化準則奉為圭臬，供整體組織及個人遵行與運用，這也是本論文為何將「75-INSAG-4安全文化中英對照翻譯」附於附錄二以供參考的原因。

his thesis is motivated from the insist on the spirit of “A gentleman devotes himself to the base of affairs; where there is the base, there is the principle”, As the term “safety culture” is originated from the accident of Chernobyl nuclear power plant in USSR, we must take this accident as example, when we explore the establishment of safety culture; further analyze, explore and ascertain it so as to understand the root causes establishing safety culture system. Through analysis and exploration on Chernobyl accident and relevant literatures, it is known that the Chernobyl accident was owing to the lack of safety culture. Thus, to ensure safety, safety culture should be established and continuously maintained. The definition of safety culture must be based on the definition proposed by the International Nuclear Safety Advisory Group (INSAG), a body who provides advice to International Atomic Energy Agency (IAEA). Definitions proposed by other scholars are just for information, so that the situation may no more fall into chaos without common consensus. After intensive exploration on literatures, it can be inferred that “Before establishment of safety culture, the attitude should be taken that both the organization and the individuals consider safety as priority, safety first or supreme”. Meanwhile, the purpose to establish safety culture is to establish the attitude of organization and the individuals to consider safety as priority or supreme. This thesis infers that current mainstreams of academic researches on safety culture performed by interview or questionnaire only present the attitude of different groups toward safety accident, but not the ultimate purpose to carry out safety culture. If it is only measuring a company or an enterprise’s safety culture and proposing improving program without further implement and examination, it is not really integrated safety culture but just discussion on paper. Therefore, the first suggestion, countermeasures and new point of view to set up safety culture into action proposed in this thesis is: setting up safety culture into action can not stop at the step of measuring safety culture and proposing countermeasures; it should be implemented continuously by following the steps of PDCA cycle and keep enforcing. Otherwise, safety culture will turn out to be bubble and empty talk without efficiency. The second suggestion, countermeasures and new point of view to set up safety culture into action proposed in this thesis is: setting up safety culture into action should follow the steps as shown in Spiral of Management . By repeated safety culture measuring and PDCA cycle, besides establishing the attitude that both the organization and the individuals consider safety as priority, safety first or supreme” as axis, gradually move safety culture spiral up. The third suggestion, countermeasures and new point of view to set up safety culture into action proposed in this thesis is: setting up safety culture into action should value INSAG-4 safety culture as criterion for the organization and individuals to follow and apply. That is why the conversion of English and Chinese 75-INSAG-4” is attached in appendix 2 for reference.