Study On The Organization Factors Of Human Errors In The Coal Mine Accidents

At present, the coal mine fatal accidents have occurred frequently in my country, and the safety situation still has been grim. The key is organizational management failures. Therefore, the paper has focused on the organization factors of human errors in the coal mine accidents.Firstly, the paper has discussed the concept and the sort of human errors. Then, the concept and the sort of the oranization errors were put forward. In according to, the Coded Fault Tree Methodology was used for analyzing of 26 coal mine fatal accidents based on the basal theories of organization errors. The result showed the distributing rule of the human errors and the oranization errors.Secondly, the paper has intruduced the concept of macroscopic or microcosmic dynamic state orangization errors and static state orangization errors, then discussed the formation mechanism of organization errors. Based on the view of the complicated socio-technical system, the paper has educed the table of the Organization Errors Shape Factors from individuals, organizations, environmental and technical points of view. 77 accidents of Shaanxi's one coal mine were analysed, then the result was analysed using Grey Relational Analysis. The result was that the root of the organization errors was mostly the failures of decision-makers'skills and responsibility, organizational surpervising and culture. The factor of Managers'decision-making that occured the most frequently had many shape factors, and these factors had no distinct difference, therefore, the managers needed to improve theirselves'whole diathesis.Thirdly, the paper has discussed the accident-causing theories and constructed the Accident-causing of Dynamic Decision-making among Three Class of Managers model. The process has combined with the Safety Management, Cognitive Psychology and Organization Behavior and so on. This model has some theoretical reference value to accident analysis, lookuping reason and preventing accidents.Finally, the paper has constructed the Integration System of Controlling Organization Errors that composed of Society Environment Basic System and Corporation Inside Controlling System and based on the systems engineering theory. Moreover, the paper has discussed the function and optimizing approaches of the safety culture, incentive mechanism and informal organization.