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研究生:陳佳吟
研究生(外文):Chia-Yin Chen
論文名稱:運用根本原因分析探討營造業職災事故並發展資料庫
論文名稱(外文):The Root Cause Analysis and Database Development of Construction Accidents
指導教授:紀佳芬紀佳芬引用關係
指導教授(外文):Chia-Fen Chi
口試委員:林希偉林志隆
口試委員(外文):Shi-Woei LinChih-Long Lin
口試日期:2019-06-12
學位類別:碩士
校院名稱:國立臺灣科技大學
系所名稱:工業管理系
學門:商業及管理學門
學類:其他商業及管理學類
論文種類:學術論文
論文出版年:2019
畢業學年度:107
語文別:中文
論文頁數:104
中文關鍵詞:意外事故分析PDCA根本原因(Root Cause)
外文關鍵詞:accident analysisaccident databasePDCARoot Cause Analysis (RCA)
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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.
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 4
第三節 研究架構 5
第二章 文獻探討 7
第一節 意外事故模型 7
第二節 意外事故分析流程 11
第三節 意外事故調查方法 15
第四節 意外事故資料及資訊系統 17
第五節 意外事故主動性改善系統 31
第三章 研究方法 38
第一節 參考他國意外事故調查方針 38
第二節 意外事故報告所需之變項 39
第三節 建立資料格式 40
第四節 分析職業意外事故災害 47
第五節 安全管理系統 50
第四章 研究結果 52
第一節 資料庫架設結果 52
第二節 變項統計分析結果 56
第三節 失誤樹分析 64
第四節 改善建議 68
第五節 營造業防災對策之探討 70
第五章 結論與建議 82
參考文獻 85
附錄 90
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