從2017年行政院的勞動年報得知，營造業的職業傷害千人率遠遠的高於各產業，因此想藉由找出意外事故的根本原因，並且加以改善，來降低營造產業的事故發生率。本研究參考加拿大雇主意外事故調查指南、新加坡工作場所安全衛生指南、美國意外事故調查書、我國重大職災報告及多位學者之研究，在Microsoft Office Access (2016版)平台上建構出意外事故資料庫模版，且分析2011-2017年期間所發生的29件意外事故案件，依照意外事故資料庫模版找出事故發生過程、罹災者基本資料，並且利用TapRooT®及五大類(不當管理、不安全環境、不安全機具、不安全材料及不安全行為)分析出意外事故的根本原因，最後將資料鍵入資料庫進行意外事故建檔及統計分析。研究結果顯示作業安全分析不確實及教育訓練危害告知不足為4成以上的意外事故發生原因，參考ISO 45001等相關安全衛生管理系統發展出一套以PDCA循環為基礎的改善模式，並提出相關的防災對策的實質建議。
本研究發現PDCA不僅可用在整個安全管理系統的實施，也可以用在各階段當中作為解決問題的方法，因此在找出根本原因之後，不但可以利用PDCA循環提升組織中的安全管理系統，也可以快速的抓出改善的方向，將意外事故分析的結果回歸應用在管理層面上。

According to 2017 Annual Report published by Taiwan Ministry of Labor, the accident rate occurred in the construction industry is higher than others. In order to increase the safety and reduce the accident rate of construction industry, it is needed to determine the accident root causes. This study referred the workplace safety and health guideline which published by Work BC, OSHA, Taiwan Ministry of Labor, and Singapore Ministry of Manpower to develop the accident database on the Microsoft Office Access. Also, we analyze 29 cases accident report published in 2011 – 2017 by one of the construction company from Taiwan. Each accident background information is put in the database. All of the cases were analyzed using TapRoot® and 5M categories to find the root cause. This study founds that category of inadequate education & training and need improve job safety analysis (JSA) contributes for more than 40% of the accidents. For the recommendation, the concept of Plan-Do-Check-Act (PDCA) is used to develop corrective action to prevent the similar accident.

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