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船舶人因事故预警管理研究
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摘要
随着世界经济的发展,各国之间交往的加强,带来经济的繁荣,国际贸易量呈飞速发展趋势,因此水上运输也变得日益繁忙。作为运输工具之一的船舶在运输链中承担着越来越重要的角色,国际贸易的飞速发展对船舶的性能也提出了相当高的要求,船舶更加趋向智能化、集成化、复杂化。随着人类科技水平的发展、社会的进步,船舶系统机器设备的可靠性有了长足的进步,由单纯的船舶硬件导致的海难事故已经鲜有发生,而人为事故成为船舶海难事故的最重要组成部分,船舶系统已经演化为典型的复杂社会技术系统,人在该系统中的作用并没有因为科技水平的提高而降低,相反这种作用在船舶海难事故中表现的愈来愈强烈,如何有效的实现对船舶人因事故的预警管理已经成为各船舶营运企业关注的头等大事,也是保障国际贸易健康快速发展、促进世界经济大发展的重要问题。
     本文对船舶系统安全事故进行了界定,澄清了长期以来人们“无事故即是安全”的错误认识,将船舶系统安全事故视为一个系统功能发挥的过程,具有系统演化的特征,并指出船舶安全事故只是该系统演化的最终阶段和形式,且对预警管理并没有重大的意义,而应该关注该系统演化的整个过程;本文详细论述了船舶安全事故的特征,并通过大量的统计数据分析了船舶安全事故的规律,指出船舶安全事故的人为特征正在逐渐加强,对船舶人因事故的预警管理将在很大程度上降低船舶事故的发生,船舶人因事故预警管理已经成为船舶营运企业安全管理的重要组成部分;本文对船舶人因事故的致因机理进行了深入的研究,详细梳理了传统事故致因理论的主要观点,研究了事故致因理论的发展脉络,指出基于牛顿范式的线性事故致因理论只能找到事故的致因要素,由此引发的对船舶人因事故的预警管理只能是事后的经验式管理,无法实现对船舶人因事故的长效预防,船舶人因事故是一个系统发挥功能的过程,该系统的结构在事故演化过程中所起的作用随着系统要素可靠性的提高而越来越重要,系统要素的相干交互作用导致的事故的结构敏感性已经成为事故的重要致因。
     根据船舶人因事故系统要素致因机理和系统结构致因机理及对预警和预警管理的辨析,本文指出船舶人因事故预警管理的最终目标是实现船舶人因事故系统的本质安全,实现对船舶人因事故的长效预防,该终极目标具有层次性,而且该层次性是和船舶人因事故系统本质安全的层次性一一对应的,每个层次都有具体的内容。船舶人因事故预警管理终极目标的层次性决定了该预警管理具有过程性、主动改进性和柔性,基于此,本文借鉴能力成熟度模型(CMM),构建了船舶人因事故预警管理的过程域模型,该模型由初级安全域、结构安全域、安全文化域三个过程子域构成,初级安全域实现的是船舶人因事故系统要素的本质安全,结构安全域实现的则是该系统构成要素之间相干交互作用的本质安全,文化安全域是三个过程子域中层次最高的子域,实现的是船舶营运企业文化的本质安全。
     对船舶人因事故系统来讲,实现其构成要素的本质安全,重点需要对其要素实施检测和评价,该系统中最重要的组成要素可以分为两类:机器设备类和人。对机器设备本质安全的研究应重点考量对其故障模式的诊断,当前对机器设备的故障诊断存在很多的方法,其中近年来兴起的支持向量机算法在故障诊断领域取得了较好的效果,但是针对小样本、多故障模式、样本不平衡的故障诊断问题,支持向量机算法也存在自身的一些缺点,为使该算法在船舶人因事故系统机器设备要素故障诊断中有更好的应用,本文提出了FCM-SVM混合算法以解决样本不平衡问题,并针对支持向量机参数难以选择的问题,提出应用粒子群算法实现参数寻优,理论上能得到最优解;对系统的另一类重要的构成要素—人的本质安全研究,本文首先界定了人员初级本质安全的概念,并深入探讨了影响其本质安全的因素,针对人员本质安全评价难以定量化的问题,本文提出以行为—后果这种输入—输出模式为评价的出发点,以输出——船舶人因事故后果为评价对象,探求输入——船舶人因事故系统个体人行为对输出的影响,找到随输入变化输出的变化规律,并认为输入和输出之间具有典型的小样本、贫信息的灰色特征,因此,本文提出应用灰色系统理论中的灰色关联分析方法评价人员的初级本质安全问题,并就灰色关联分析方法对指标权重比较敏感的特性,提出了熵权优化的灰色关联方法,较好的反映了样本数据的信息。
     船舶人因事故的结构敏感性导致了传统事故致因理论因果律失效,船舶人因事故中“同果不同因”、“同因不同果”是普遍存在的现象,其结构敏感性在人因事故发生、演化过程中突出表现为出船舶人因事故系统的脆性,该性质的发现很好的解释了当前船舶人因事故预警管理存在的“头痛医头脚痛医脚”的被动的、事后的、经验的预警管理模式无法实现对事故长效预防的原因,通过对该系统脆性的研究更进一步深化了事故的结构致因机理,明确了事故演化的规律,通过对该系统脆性熵变及系统脆性关联的研究,较好的贯彻了“安全第一,预防为主”的船舶人因事故预警管理宗旨。
     企业本质安全文化是实现船舶人因事故长效预防的关键要素,是船舶人因事故预警管理过程域中层次最高的过程子域,它以弥漫式的潜移默化作用影响船舶人因事故系统的方方面面,实现船舶营运企业安全文化的本质化是船舶人因事故预警管理的关键所在,本文从物态文化建设、制度文化建设、精神文化建设三面着手深入研究了船舶营运企业本质安全文化的建设模式问题,指出了该本质安全文化建设的目标及原则。
The economic prosperity, rapid growth of international trade has been brought forward with the high-speed development of global economy and the enhanced communication among defferent countries. The water transport becomes busier and busier, and the ship becomes more and more important as one of conveyances in the transportation chain, so the rapid development of international trade puts forward rather high requirement, and the ship becomes more and more intelligent, integrated and complicated. The reliability of machinery equipment in ship system has become much higher with the development of human science and technology level and the advancement of society, so the maritime accidents due to ship machinery equipment has occurred less and less, but the maritime accidents due to human factors has been the main component of maritime accidents. The ship system has become a typical and complex socio-technical system, in which the role that human plays in this system does not become little because of the advanced science and technology level, In contrary the role becomes stronger and stronger in maritime accidents. How to implement forewarning management on ship accidents due to human factors has been the most important event to ship transportation enterprises, which is also the important event for the rapid growth of international trade and high-speed development of global economy.
     This paper defines ship system safety accident, and clarifies the cognition of "where is no accident, where is safe" which effects people for a long time, and believes that the ship system accident is a process of a system function exerting which has the typical system evolution features. And this paper points out that the ship safety accidents are the merely utimate stage and form of system evolution, which has less great significance for ship accidents forewarning management, and the whole process of system evolution should be paid great attention; This paper discusses the characteristics of ship safety accidents detailedly, and analyses the rules of ship safety accidents based on a mass of statistical data. Based on the rules, this paper points out that the human factors of ship safety accidents has been enhancing, so the effective forewarning management of ship accidents due to human factors will reduce the incidence rate of ship safety accidents to a great extent. The forewarning management of ship accidents due to human factors has been the most important component of safety management in ship transportation enterprises. This paper studies the causation mechanism of ship accidents due to human factors deeply, in which the traditional accidents causation theories'main viewpoints are carded detailedly and the development vein of accidents causation theories is studied deeply. Based on the achievements from the research on traditional accidents causation theories, this paper points out that the traditional linear accidents causation theories which is based on Newtonian paradigm following the philosophical thinking of Descartes can only find out the causation elements of accidents, and the forewarning management of ship accidents is ex post facto empirical management which can not achieve the long-term prevention to ship accidents due to human factors. The ship accidents due to human factors is the process of a system exerting function, and the structure of the system plays more and more important role in ship accidents due to human factors evolution with the reliability of system elements being improved increasingly. The sructure sensitivity of the ship accidents due to human factors from the coherent interaction among system elements has been the most important causation.
     In the basis of the discrimination of forewarning and forewarning management and system elements causation and system structure causation of ship accidents due to human factors, This paper points out that the ultimate object of forewarning management on ship accidents due to human factors is to realize the intrinsic safety of the ship accidents system due to human factors, and to realise the long-term prevention on ship accidents due to human factors. This object has the typical hierarchy, which matches the hierarchy of ship accidents system due to human factors intrinsic saftey, and there is detailed content in each hierarchy. The hierarchy of the ultimate object in forewarning management on ship accidents due to human factors determines that the forewarning management has the characteristics of process nature, active improvement nature and flexibility nature. So, this paper establishes the process area model for ship accidents due to human factors in the basis of Capability Maturity Model(CMM), and the model consists primary safety area, structural safety area and safe culture area. The primary safety area realizes the intrinsic safety of system elements in ship accidents system due to human factors, and the structural safety area realizes the intrinsic safety of the coherent interaction among system elements, while the safe culture area is on the highest hierarchy realizing the intrinsic safety of ship transportation enterprise culture.
     To realize the intrinsic safety of system elements in ship accidents system due to human factors, the most important is to make some checking and evaluating. The elements in the ship accident system due to human factors consist two parts:the machinery inquipment and man. The study on the intrinsic safety of machinery inqipment should pay attention to the fault diagnosis. And there are a lot of methods to carry out fault diagnosis to machinery equipment, among of which the Surport Vector Machine newly popular in recent years has got better effect in fault diagnosis. But SVM has some disadvantages in solving fault diagnosis problems with the characteristics of small sample, multi-fault pattern and sample imbalance. In order to implement SVM in machinery equipment fault diagnosis better, this paper puts forward FCM-SVM hybrid algorithm to solve the problem of sample imbalance, and according to the problem that paramenters of SVM are not easy to select, this paper brings forward implementing PSO algorithm to realize parameters optimization which can get the theoretical optimal solution; About another important element's intrinsic safety in ship accidents system due to human factors-human, this paper defines the definition of primary intrinsic safety of human, and discusses the factors that affect its primary intrinsic safety deeply. According to the problem that it is difficult to quantitatively evaluate the primary intrinsic safety of human, this paper takes "Behavior-Consequence" as the starting point, and takes the consequence of ship accidents due to human factors as the evaluating objects to hunt for the relationship between behavior and consequnce, and also hunts for the variation law between the input and output. The relationship between the input (behavior) and output(consequence) has the typical grey characterisrics of small sample and poor information. So, this paper brings forward using grey relational analysis method in grey system theory to evaluate human's primary intrinsic safety problems, and according to the characteristic that grey relational analysis method is sensitive to index weight, this paper utilizes entropy weight to optimize grey relational analysis which can preserve sample's information better.
     The structure sensitivity causes the failure of causality in traditional accidents causation theories, and in ship accidents due to human factors, it is universal that the same causation has different consequence, and the same consequence has different causation. The structure sensitivity in ship accidents due to human factors manifests as the brittleness of the system, and this characteristic of ship accidents system due to human factors explains the reason why the current ship accidents forewarning management which is the unilateral, ex post facto empirical management can not realize the object of long-term prevention on ship accidents due to human factors. The structure causation mechanism and the evolution rule of ship accidents due to human factors are known about deeply based on the study on brittleness of the system. After the research on system brittleness entropy change and system brittleness association, the model carries out the ship accidents forewarning management due to human factors tenet of "safety first, prevention first".
     The intrinsic safety culture of the enterprise is the key factor to realize the object of long-term prevention for ship accidents due to human factors, and it is also in the highest level of forewarning management. The intrinsic safety culture affects the ship accidents system due to human factors detailedly, and how to realize the intrinsic safety culture is the key factor for ship accidents due to human factors forewarning. This paper studies on the intrinsic safety culture construction mode of ship transportation enterprises in the consideration of material culture construction, system culture construction and spiritual cultural construction, and points out the construction object and principle.
引文
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