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天津港“8.12”特别重大火灾爆炸事故敲响了危险化学品行业安全状况的警钟，为明晰各事故原因的因果关系和事故致因路径，本文选取2个典型的事故致因链：事故致因“2-4”模型和“三要素”理论，分别分析事故的直接原因、间接原因、根本原因和根源原因的具体内容，以及事故的危险源和隐患的因果关系。结果表明：组织行为的控制缺欠导致个人行为出现差错，进而主导事故的发生；危险源失去管控，将形成隐患，隐患没能及时消除，将会发展成为事故。进而在事故调查报告基础上，结合事故分析结果，从不安全动作的防范、安全管理体系的完善和安全文化的建设3方面提出对策措施，为危险化学品行业提高安全管理水平提供理论依据和技术参考。
Abstract：The Tianjin Port "8. 12" especially serious fire and explosion accident sounded an alarm bell for the safety situation of the hazardous chemical industry. In order to clarify the causality of accident causes and the accident causation route,in this paper,two typical accident causation chains of24model and theory of three essential elements were selected to analyze the direct causes,indirect causes,basic causes and root causes of the accident respectively,as well as the causality between hazardous sources and hidden dangers. The results showed that the individual behavior occurred errors due to the control defect of the organizational behavior,and then caused the occurrence of accidents;and that if hazardous sources were not under control,there would formulate hidden dangers,and then if hidden dangers were not eliminated timely,there would develop into accidents. On the basis of the accident investigation report and combining with analysis results of the accident,countermeasures were put forward from three aspects of preventing from unsafe actions,improving safety management systems,and constructing safety cultures,aiming at providing theory foundation and technical reference for the hazardous chemical industry to increase the safety management level.
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基本信息:
DOI：10.19737/j.cnki.issn1002-3631.2022.05.009
中图分类号:X928.7
引用信息:
[1]马小林,昌伟伟.基于事故致因链的天津港“8.12”火灾爆炸事故分析[J].安全,2022,43(05):56-61.DOI:10.19737/j.cnki.issn1002-3631.2022.05.009.
基金信息:
国资委中央企业“科技兴安”研究课题（K21014BK）; 北京工业职业技术学院科研课题（BGY2022KY-29）