| The current accident investigation reports do not systematically apply the accident causation model for in-depth analysis of the causes based on the serious and extra serious accidents investigation reports.The causes of accidents in the reports are more investigated than analyzed.There is much room for improvement in the specificity and variability of the accident causes obtained.The prevention countermeasures proposed based on the current accident analysis results are highly similar and difficult to implement.The main reason is that the current accident causation models mainly come from foreign countries.Because of language and other factors,there are some ambiguities in the definition,classification,logical relationship,and action process of causes.Based on this,24 Model and SCM are selected for comparative study to deepen the understanding of the two models,and put forward the optimization and improvement of 24 Model.It has significant theoretical and application value for the development of 24 Model.The main conclusions of this thesis are as follows:1)Reveal the differences between 24 Model and SCM model structure and model connotation.24 Model and SCM are behavioral evolution models based on causality,while 24 Model has two structural forms: static and dynamic.Static 24 Model represents the system state at the time of the incident,and dynamic 24 Model represents the behavioral evolution system.24 Model pays attention to the connotation and classification of each module,keeps the independence and connection between each other,and facilitates the cause location.SCM model mainly focuses on the system’s defense and visually shows the process of accidents.However,there is no exact definition of related concepts,and only examples are given to analyze various causal factors,which leads to cognitive bias in the application and poor reliability of cause identification.Comparative research on the causal structure and connotation of 24 Model and SCM provides the necessary theoretical basis for effectively identifying the cause of accidents and systematically carrying out the application research of 24 Model and SCM.2)Determine the differences between 24 Model and SCM in accident cause analysis.It mainly includes the difference between the reliability of analysis results and statistical analysis results of large samples of accidents.(1)The precise meaning of the cause module in 24 Model ensures the repeatability and reliability of cause tracing.24 Model analysis results are more comprehensive and reliable than HFACS.(2)The definition and division of causes provide a suitable data structure for mining extensive sample accident causes.The reason category of HFACS can effectively reduce the dimension of large sample accident data,which makes it possible to mine deep associations of cause data.The visualization effect of significant sample accident analysis results is better than that of 24 Model,which can learn from and further optimize the data structure of the models,and provide a basic framework for further application of large sample data.3)Clarify the categories and concepts of 24 Model.Comparing with SCM,the organizational boundary,accident definition,cause category,and action process are further clarified.Static 24 Model can provide framework support for cause location,and dynamic 24 Model can provide an identification method for cause tracking,and build a complete cause chain for accident occurrence and development,which is convenient for learning and application of accident lessons.The clear module connotation provides a good foundation for the practical application of 24 Model in the field.4)The guideline of the 24 Model was developed and verified by examples.Based on the comparative study results of accident causes analysis,the data of the safety management system and unsafe acts of 24 Model analysis results are enormous,which is not conducive to data mining and utilization.The classification system of 24 Model is optimized to provide structured results for accident statistical analysis and ensure the visualization of analysis results.A description table of reasons subcategories is offered to provide the basis for reasons determination.The hidden cause analysis path is developed based on static and dynamic 24 Model.The analysis process and analysis steps are developed according to the analysis framework.The standardized incident analysis process based on the guidline avoids the subjectivity of the analysis results.The reliability of the guidline has been verified by the test team,which can promote the application and popularization of 24 Model in the industrial field.5)Build a security management practice mode based on 24 Model.The reliability of the 24 Model application guide fully proves its scientificity.Based on this,the practical manner of safety management is put forward,hoping that the thinking of the accident causation model can run through the safe operation of the whole organization and control the safety links to realize the transformation from post-event management to pre-event management.Put forward an improvement plan for accident investigation and analysis,make an in-depth analysis of the cause of the accident,improve the quality of the accident investigation report,provide reliable supporting materials for drawing lessons from the accident,and build a safety barrier from the top to bottom according to the model framework of accident causes,to effectively prevent the occurrence of similar accidents. |