基于高可靠性组织理论的事件学习系统方案设计研究

发布时间：2018-01-28 22:56

本文关键词： 事件学习系统高可靠性组织理论系统思考成长上限基模　出处：《中国地质大学(北京)》2017年硕士论文　论文类型：学位论文

【摘要】：理论和实践表明,事故在发生以前往往已经出现过类似的状况或者有一些“前兆”或警告,但是事发组织并未成功地收集和分析这些事件信息进而及时采取适当的纠正措施以减少风险,从而导致风险扩大发生灾难。组织不能有效的从已经发生的事故或事件中学习经验教训是事故或事件会持续不断出现的一个重要原因。本文在梳理事件学习研究现状的基础上,提出在企业中构建事件学习系统预防类似事故的必要性。在本文中事件被定义为生产过程中发生的可能对安全、健康、环境造成不利影响的不期望事件,包括灾难、事故、险兆事件、操作失误、警告以及一些征兆等都可以作为学习的对象。通过对影响事件学习效果因素的总结归纳,提取出了影响事件学习效果的事件上报、调查分析、信息交流和措施整改中的障碍并对各影响因素的具体表现形式进行了说明。为提高事件学习效果,预防类似事故的再次发生,结合高可靠性组织理论,利用高可靠性组织的属性对事件学习的过程做指导,建立了包含事件报告、事件优选、事件调查分析、信息传播、改正措施和效果评估在内的六个步骤的事件学习系统,并对每个阶段的内容、方法以及具体的实施流程做了详细的设计。为了验证事件学习系统的有效性,基于系统思考的思想,运用系统思考的基本工具-“成长上限”系统基模对影响事件学习效果的因素进行了分析,建立了影响事件学习的事件上报、调查分析、信息传播和实施改正措施的子基模。通过整合高可靠性组织理论的整改措施以减弱负反馈回路,并对子基模做并运算形成了事件学习系统的“成长上限”基模。这一基模在理论上验证了基于高可靠性组织理论的事件学习系统可以克服事件学习过程中存在的问题,通过不断地改进调整不断提高事故预防能力。最后,就企业在实际安全管理中开展事件学习活动提出了几点意见。
[Abstract]:Theory and practice show that accidents often have a similar situation or some "foreboding" or warnings before they occur. However, the organization did not succeed in collecting and analysing the incident information and taking appropriate corrective measures in time to reduce the risk. It is an important reason that the accidents or events will continue to occur continuously. This paper reviews the study of event learning in order to learn the lessons from the accidents or events that have already occurred. On the basis of the status quo. The necessity of building an event learning system in an enterprise to prevent similar accidents is proposed. In this paper, the event is defined as an undesirable event that may have adverse effects on safety, health and environment in the production process. Including disasters, accidents, dangerous events, operational errors, warnings, and some signs can be used as learning objects. In order to improve the effect of event learning, the obstacles in incident reporting, investigation and analysis, information exchange and measures correction are extracted and explained. To prevent the recurrence of similar accidents, combined with the high reliability organization theory, using the attributes of high reliability organization to guide the process of event learning, including event reporting, event selection, event investigation and analysis. Information dissemination, corrective measures and impact assessment include the six-step event learning system and content for each stage. In order to verify the effectiveness of the event learning system, it is based on the thought of system thinking. Using the basic tool of systematic thinking, the "growth upper limit" system model, this paper analyzes the factors that affect the effect of event learning, and establishes the event report and investigation analysis that affect the event learning. Information dissemination and implementation of corrective measures submodel. By integrating the high reliability of the organization theory of corrective measures to reduce the negative feedback loop. The "growth upper limit" of the event learning system is formed by performing parallel operations on the subbasic modules. This model theoretically verifies that the event learning system based on high reliability organization theory can overcome the problems in the process of event learning. Through continuous improvement and adjustment, the ability of accident prevention is improved. Finally, some suggestions are put forward for the enterprise to carry out the event learning activities in the actual safety management.
【学位授予单位】：中国地质大学(北京)
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：X928

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