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Analysis of soma mine disaster using causal analysis based on systems theory (CAST)

机译：基于系统理论的因果分析（铸造）分析SOMA煤矿灾害分析

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摘要

Analyzing accidents of sociotechnical systems requires an understanding of the system safety structure. Among various methods proposed for accident analysis in complex sociotechnical systems the Systems-Theoretic Accident Model and Processes (STAMP) model is one of the most widely used model for predictive applications in the literature. The STAMP accident causality model with the accident analysis tool, called CAST (Causal Analysis based on Systems Theory) is an effective method for accident analysis. The Soma Mine Disaster (SMD), which occurred due to a fire in the underground coal mine and caused 301 fatalities in 2014, is one of the largest mine disasters in the last few decades. Although mine fires usually do not cause large number of casualties as compared to explosions in underground coal mines, the SMD has one of the highest number of deaths in the 21st century. In this paper, the CAST, which is based on STAMP is used for analyzing the SMD as it provides a system engineering perspective in accident analysis. Considering the complex nature of the SMD, a variety of factors were involved in the high number of casualties. Among them, socio-technical factors like unstructured organizational and human performance as well as inadequate safety culture, improper decision making and risk perception, which played a critical role in the SMD, are defined in an integrated system thinking framework. Finally, inadequate system control constraints are identified in each hierarchical level of the system and improvements are suggested, accordingly. It is also demonstrated that a CAST analysis is robust for the cases like the SMD, which involves high degree of uncertainty related to the occurrence of the accident. The analyses presented in this paper also show the design of prevention and mitigation measures against such disasters in different levels of the accident control hierarchy.
机译：分析社会科技系统事故需要了解系统安全结构。在复杂的社会技术系统中提出的各种方法中，系统 - 理论意外模型和流程（印章）模型是文献中最广泛使用的预测应用模型之一。与事故分析工具的邮票事故因果关系模型称为铸造（基于系统理论的因果分析）是事故分析的有效方法。 Soma矿区灾难（SMD）发生在地下煤矿的火灾和2014年造成301个死亡，是过去几十年中最大的矿山灾害之一。虽然矿山火灾通常不会导致大量伤亡与地下煤矿的爆炸相比，但SMD在21世纪的死亡人数最多之一。本文基于邮票的演员用于分析SMD，因为它提供了在事故分析中提供了一种系统工程视角。考虑到SMD的复杂性，各种因素涉及大量伤亡。其中，社会技术因素，如非结构化的组织和人类绩效以及在SMD中发挥着关键作用的安全文化，不正当的决策和风险感知，在综合系统思维框架中定义。最后，在系统的每个层级中识别系统控制约束不足，因此提出了改进。还表明，对于SMD等案例，施放分析是强大的，这涉及与事故发生相关的高度不确定性。本文提出的分析还显示了防止和减缓措施对不同水平的不同水平的灾害的设计。

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  • 来源
    《Safety science》 |2018年第1期|共21页
  • 作者

    Duzgun H. Sebnem; Leveson Nancy;

  • 作者单位

    Colorado Sch Mines Min Engn Dept 1500 Illinois St RM 268 Golden CO 80401 USA;

    MIT Dept Auronaut &

    Astronaut 33-334 77 Massachusetts Ave Cambridge MA 02139 USA;

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  • 原文格式 PDF
  • 正文语种 eng
  • 中图分类 安全科学基础理论;
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  • 入库时间 2022-08-20 05:28:11

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