臺灣博碩士論文加值系統

從我國過去重大職災的資料顯示，大多數的重大職業災害都屬於營造業墜落職災。因此，分析意外事故對我國預防職業災害而言是很重要的議題。近年來以圖形分析意外事故，已經被廣泛的用來預測事故的發生原因，如：失誤樹、事件樹、原因後果圖。國外學者Rasmussen發展出一套圖形表現工具AcciMap，這種方法與其它事故分析技術不同在於，它是從發生意外事故的各個層面中找出致災因素，範圍從事件的發生和當事人所從事的活動，追朔至政府部門、法令與社會層面的原因。有別於其他分析方法，將各階層所有原因整合為圖形，以呈現相互作用的因果關係，避免未來重複發生類似的事故。
以往分析墜落職業災害的研究，對於所發現之事故原因往往著重於不安全行為或狀況。為了深入瞭解各階層所做的決策如何影響意外事故的發生，以免只注意到與意外事故直接有關的事件或人為疏失。本研究應用AcciMap的六個層級架構為基礎，利用層級化的方式，分析2001~2005年這段期間，414件營造業墜落重大職災個案報告，從中找出影響墜落職災發生的致災因素、承攬階層以及各承攬階層所觸犯的法律規章，並利用編碼方式將上述資料予以建檔進行統計分析之件數，最後歸納整個結果建構出一個多層次的營造業墜落職災AcciMap圖形，呈現一系列造成勞工墜落的危害過程。透過本研究的結果顯示，勞工發生墜落很少為單一原因，通常是多項原因一起引發的，各組織階層所做的決策或行為都會層層互相影響，形成擴大效應的現象，最後導致勞工墜落罹災死亡，不單只是勞工的個人因素，組織階層的管理因素也是造成勞工發生墜落的因素之一。此外，還可依據上述的結果，進一步探討每個階層如何預防墜落職災的發生。

Fatal falls was the first leading cause of occupational fatality in the construction industry of Taiwan. Accident analysis is an important source of information for developing prevention strategies and making decisions. Graphic representations of the causal flow accident have been applied extensively to the analysis of accident and its causation, for example: fault trees, event trees, and cause-consequence charts. Rasmussen（1997）developed a graphic representation of tool named AcciMap. This approach differs from other accident analysis techniques by identifying causal factors from all layers of the system in which the accident took place, ranging from the physical sequence of events and activities of the individuals involved, right up to the causes at the governmental, regulatory and societal levels. Unlike other accident analysis methods, the AcciMap assembles the contributing factors into a coherent causal diagram that illustrates the interrelationships between them, thereby highlighting the problem areas that should be addressed to prevent similar accidents from occurring in the future.
Previous studies of fatal falls often focus on unsafe behavior and environment. Further understand of how decision makers at different levels affect the accident, so that attention is not directed solely towards the events and human errors that led directly to the accident. This study analyzed 414 falling fatalities of construction industry from the years 2001 to 2005 based on six levels of AcciMap structure. Each accident was analyzed in terms of causes of fall, number of subcontracting layers, and violations of laws and regulations for each subcontracting layer. The result was illustrated in terms of AcciMap to show that fatal falls was not only caused by personal factors of the victim. It showed the interrelated decisions and performing tasks at different layers of the organization.

目錄
摘要 I
ABSTRACT II
誌謝 III
目錄 IV
表目錄 VI
第一章 緒論 1
第一節 研究動機與目的 1
第二章 文獻探討 4
第一節 AcciMap 4
2.1.1理論發展 4
2.1.2基礎概念與架構 8
2.1.3應用領域 11
第二節 其他意外事故理論與分析方法 23
2.2.1意外事故理論 23
2.2.2其他意外事故分析方法 26
第三節 營造業墜落重大職災相關文獻 28
2.3.1營造業的特性 28
2.3.2我國政府防止職業災害機構 29
2.3.3勞工安全法規 31
2.3.4國內外營造業墜落職災相關研究 32
第三章 研究方法 33
第一節 資料用途說明 33
第二節 定義營造業墜落職災各組織層級 34
第三節 資料處理過程與編碼 38
3.3.1墜落原因編碼 38
3.3.2承攬關係編碼 44
3.3.3各承攬階層違法法規編碼 44
第四節 定義營造業墜落職災AcciMap的符號 54
第四章 研究結果 56
第一節 統計分析 56
4.1.1墜落原因 56
4.1.2承攬階層 58
4.1.3勞工安全衛生法 60
4.1.4勞工保險條例 69
4.1.5勞動基準法 70
4.1.6刑法 71
4.1.7勞工安全衛生設施規則、營造安全衛生設施標準 72
第二節 營造業墜落重大職災之AcciMap 76
第五章 討論 81
第六章 結論與建議 87
參考文獻 88

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