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研究生: 林暄茲
Syuan-Zih Lin
論文名稱: 運用失誤樹分析夾捲重大職災事故
Fault Tree Analysis for Caught-in-Between Occupational Fatal Accidents
指導教授: 紀佳芬
Chia-Fen Chi
口試委員: 黃煌煇
Hwung-Hweng Hwung
鄒子廉
江行全
Bernard C. Jiang
林義貴
Yi-Kuei Lin
學位類別: 博士
Doctor
系所名稱: 管理學院 - 工業管理系
Department of Industrial Management
論文出版年: 2018
畢業學年度: 106
語文別: 中文
論文頁數: 81
中文關鍵詞: 失誤樹布林代數最小分割集合
外文關鍵詞: Fault tree, Boolean algebra, Minimal Cut Set(MCS)
相關次數: 點閱:603下載:11
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職業災害調查報告分析是制定預防職業災害的措施以及決策的重要資訊來源。本研究分析臺灣於1996~2007年期間所發生的312個夾捲重大職災死亡案例,建立一套具有綜合性和互斥的編碼方式。針對每個夾捲重大職災案例中罹災者的年齡、性別、工作經驗、行業別、媒介物(機器類別,source of injury)和發生原因。除了運用統計法分析312個案例的各個類別因素之間的關聯性之外,並運用失誤樹中的布林代數(Boolean algebra)分析媒介物的發生根本原因以及最小分割集合(minimal cut set, MCS)。研究結果顯示,關於以下七種災害類型的機器(1)特別加工機械,包括紡織,印刷,包裝機械(special process machinery including textile, printing, packing machinery),(2)金屬,木工和特殊材料機械(metal, woodworking, and special material machinery),(3)輸送機(conveyor),(4)車輛(vehicle),(5)起重機(crane),(6)工程機械(construction machinery),(7)電梯(elevator),導致重大意外事故的發生原因,根據布林代數進行最小分割集合(minimal cut set, MCS)的分析,可將上述七種機器類別可分為三大類。最小分割集合(minimal cut set, MCS)的結果,例如:將特別加工機械,包括紡織,印刷,包裝機械(special process machinery including textile, printing, packing machinery)和金屬,木工和特殊材料機械(metal, woodworking, and special material machinery)與和輸送機3種類型因具有的相同主要致災原因,將此3種類型機械歸為同一類致災來源。
本研究發現運用布林代數邏輯原理簡化的格式合併其他發生原因,產生新分類的致災來源機械類型,不僅可以聚焦在重要失誤並發展重要預防方法,關於每項致災來源(機器類別,source of injury)根本原因的組合,可以根據本研究分群結果進而發展出精確和有效的預防措施。


Accident analysis is an important source of information for developing prevention measures and making decisions. The current study analyzed 312 caught-in-between fatalities caused by machinery and vehicles. A comprehensive and mutually exclusive coding scheme was developed to analyze and code each caught-in-between fatality in terms of age, gender, experience of the victim, type of industry, source of injury, and causes for these accidents. Boolean algebra analysis was applied on these 312 caught-in-between fatalities to derive minimal cut set (MCS) causes associated with each source of injury. Eventually, contributing factors and common accident patterns associated with (1) special process machinery including textile, printing, packaging machinery, (2) metal, woodworking, and special material machinery, (3) conveyor, (4) vehicle, (5) crane, (6) construction machinery, and (7) elevator can be divided into three major groups through Boolean algebra and MCS analysis. The MCS causes associated with conveyor share the same primary causes as those of the special process machinery including textile, printing, packaging and metal, woodworking, and special material machinery.
These fatalities can be eliminated by focusing on the prevention measures associated with lack of safeguards, working on a running machine or process, unintentional activation, unsafe posture or position, unsafe clothing, and defective safeguards. Other precise and effective intervention can be developed based on the identified groups of accident causes associated with each source of injury.

摘要……………………………………….………………..…….….I Abstract……………………………………..…………………………………….II 誌謝………………………………………………..………….….……III 目錄…………………………………………….………….………………………IV 圖目錄……………………………………………………………………………..V 表目錄………………………………………………………………………..…..VI 第一章 緒論………………………………………………………………………1 第一節 研究背景與動機…………….……………………………………1 第二節 研究目的…………………………….……………..……………..7 第三節 名詞定義、研究範圍與限制……………………….……..………..7 第四節 研究組織架構…………………………………….………..….……8 第二章 文獻探討……………….……………………………….……………..11 第一節 夾捲意外事故調查分析………………………………………….11 第二節 職業災害致災因素………………………………...……………14 第三章 研究方法………………………………………………….………….27 第一節 資料資料來源與變項定義……………..……………….……….27 第二節 相關性分析………..……...………………………………………28 第三節 失誤樹分析………………..……………………….…………..…30 第四章 夾捲重大職災統計分析……………………………………….………35 第一節 變項統計分析結果………………………………………….……35 第二節 結論與討論…………………………………………………...….42 第五章 失誤樹最小分割集合分析…………………………………….…44 第一節 最小分割集合分析(布林代數簡化)……… …………………..44 第二節 失誤樹的使用效益……….………..…………………………….56 第三節 結論與討論………………………………………………………59 第六章 結論與建議……………………………………………………………..63 參考文獻……………………………………………………………….………65 附錄………………………………………………………………...………………70

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