本文選題：煤礦　切入點：瓦斯爆炸事故　出處：《中國礦業(yè)大學(xué)(北京)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：事故原因分析是事故預(yù)防的基礎(chǔ)。針對近年來煤礦重特大瓦斯爆炸事故占全部煤礦重特大事故的比例不斷增大、事故發(fā)生起數(shù)和造成的死亡人數(shù)居高不下的情況,本文研究了以往學(xué)者對煤礦井下瓦斯爆炸事故的原因分析,發(fā)現(xiàn)以往原因分析主要集中在導(dǎo)致事故的不安全動作和不安全物態(tài)等直接原因上,較少涉及直接原因背后更深層次的個人習(xí)慣性行為原因和管理體系原因之研究,且在研究員工不安全動作原因時,僅考慮一線班組員工的違章動作,較少的考慮管理層員工的不安全動作原因等問題。從事故預(yù)防角度來說,盡可能全面分析現(xiàn)階段事故中人和物的原因、個人和組織等的原因,才能更全面、有效的為現(xiàn)在和將來的事故預(yù)防工作提出切入點、思路或是側(cè)重點,以及為員工培訓(xùn)提供指導(dǎo)和參考。為達(dá)到上述研究目的,本文以事故致因“2-4”模型為理論依據(jù),研究了瓦斯爆炸事故的原因分析方法,并選取2005-2014年間發(fā)生的105起重特大瓦斯爆炸事故進(jìn)行研究分析。首先,從事故發(fā)生井下地點、事故發(fā)生時間、死亡人數(shù)、礦井瓦斯等級、礦井所有制信息等幾個方面對2005-2014年重特大瓦斯爆炸事故的致因因素規(guī)律進(jìn)行了統(tǒng)計分析;其次,從點火源和瓦斯積聚兩個角度分別分析了導(dǎo)致事故發(fā)生的不安全動作原因、不安全物態(tài)原因、習(xí)慣性行為原因和安全管理體系缺欠原因等各類原因;最后,簡單建議了本文所得到的事故原因分析結(jié)果在瓦斯爆炸事故預(yù)防中的應(yīng)用方法,得到以下結(jié)論:(1)提出一個以員工行為為出發(fā)點的事故分析方法。事故致因“2-4”模型是理論模型,為實際應(yīng)用在事故分析中,本文提出了一種7步分析方法,包括(1)切割組織;(2)事故發(fā)生經(jīng)過分析;(3)事故組織內(nèi)員工不安全動作的識別;(4)不安全物態(tài)原因分析;(5)習(xí)慣性行為原因討論;(6)安全管理體系缺欠原因分析;(7)事故原因的歸納及其對事故的影響過程分析。(2)得到了近年來煤礦重特大瓦斯爆炸事故的致因因素規(guī)律。通過對2005-2014年間發(fā)生的105起煤礦重特大瓦斯爆炸事故的致因因素進(jìn)行統(tǒng)計分析發(fā)現(xiàn):隨著安全管理水平的提高,放炮火焰和電火花、或是人為導(dǎo)致的通風(fēng)管理問題正逐漸被解決,瓦斯爆炸事故發(fā)生的物理過程向更難以預(yù)防、更隱蔽的密閉空間瓦斯積聚和熱輻射、摩擦撞擊火花等原因轉(zhuǎn)變。(3)得到了事故中引起點火源和瓦斯積聚的“原因圖譜”(見附錄C)。通過分析樣本事故的各類原因,按原因發(fā)生的頻次,得到了引起瓦斯爆炸事故發(fā)生的“原因圖譜”。(4)得到了瓦斯爆炸事故中引起點火源的各類原因及其規(guī)律:分析產(chǎn)生放炮火焰的原因發(fā)現(xiàn),封孔和炸藥及爆破器材的管理是引起放炮火焰最多的兩類原因。另外,有36起事故未組織爆破工進(jìn)行專業(yè)培訓(xùn),37個事故礦井在日常作業(yè)中出現(xiàn)違章指揮、忽視、縱容工人違章放炮的行為,38個事故礦井爆破前未建立或未要求執(zhí)行爆破作業(yè)說明書,這些原因共同促使爆破工形成習(xí)慣性違章爆破行為。分析產(chǎn)生電火花的原因發(fā)現(xiàn),操作失爆的電氣設(shè)備(17)、帶電檢修電氣設(shè)備(9)是直接引起事故的主要不安全動作原因。17類不安全物態(tài)原因中有16類屬于電氣設(shè)備失爆,其中煤電鉆電纜線明接頭(11)出現(xiàn)最多,41個事故礦井中有36個礦井未安裝供電閉鎖和超前切斷電源控制設(shè)備,說明事故礦井普遍缺乏對供電閉鎖作用的認(rèn)識。另外,由于事故礦井缺失有關(guān)電氣設(shè)備和電纜檢修(38),防爆電氣設(shè)備全生命周期的使用和管理(21),電氣設(shè)備檢修臺賬(19)等相關(guān)規(guī)定,才導(dǎo)致大量帶電檢修不安全動作和失爆電氣設(shè)備的出現(xiàn)。分析產(chǎn)生明火和熱輻射的原因發(fā)現(xiàn),大部分事故是因為未定期檢查密閉的完好性和漏風(fēng)情況、沒有采取防采空區(qū)漏風(fēng)措施(7)、對于井下長期存在煤自燃預(yù)兆或存在火區(qū)未采取有針對性的防滅火措施(6)等忽視密閉破損(7)、采空區(qū)溫度上升、頂板有水珠等自燃發(fā)火征兆(6)的不安全動作引起的。另外,在13起事故中只有3個事故礦井未安裝采空區(qū)溫度檢測或預(yù)警系統(tǒng)和防滅火系統(tǒng),說明事故礦井并非是工程技術(shù)手段未到位,而是管理未落實。分析產(chǎn)生摩擦沖擊火花的原因發(fā)現(xiàn),對于預(yù)防摩擦沖擊火花,需要避免直接操作金屬設(shè)備時發(fā)生的碰撞,注意機電設(shè)備的安裝位置、方向和維修管理、特別是備用機電設(shè)備的完好性,以及重視頂板管理三個方面。同時,應(yīng)在員工培訓(xùn)中強調(diào)摩擦沖擊火花發(fā)生的可能(8)。(5)得到了瓦斯爆炸事故中引起瓦斯積聚的各類原因及其規(guī)律:分析造成礦井供風(fēng)量不足的原因發(fā)現(xiàn),直接管理層員工甚至是礦級管理層員工是造成礦井供風(fēng)量不足的主要決策者。礦級管理層員工由于缺乏礦井通風(fēng)相關(guān)知識,導(dǎo)致私自全礦井停電(8),不采用機械通風(fēng)(7)、超層開采(6)或是超能力開采(3)的頻頻發(fā)生,從而導(dǎo)致礦井供風(fēng)量不足。分析造成局部通風(fēng)管理混亂的原因發(fā)現(xiàn),掘進(jìn)工作面未使用局部通風(fēng)機(9)、局部通風(fēng)機安裝位置錯誤導(dǎo)致拉循環(huán)風(fēng)(8)等是引起工作面有效風(fēng)量不足的主要不安全動作原因;43起事故中涉及的主要不安全物態(tài)有三類,與局部通風(fēng)機有關(guān)的出現(xiàn)30次、與風(fēng)筒有關(guān)15次、另外5次與通風(fēng)構(gòu)筑物有關(guān);相應(yīng)的,反映出事故礦井員工較多缺乏諸如局部通風(fēng)機拉循環(huán)風(fēng)的原因和危害(15)、隨意開停局部通風(fēng)機的危害(8)等安全知識;同時通風(fēng)區(qū)隊普遍存在未能履行其崗位責(zé)任的情況,局部通風(fēng)機安裝、使用、管理(16),風(fēng)筒使用、檢查、維護管理(15)等相關(guān)規(guī)定也存在較多的缺欠。分析造成通風(fēng)系統(tǒng)不合理的原因發(fā)現(xiàn),采區(qū)通風(fēng)構(gòu)筑物設(shè)置錯誤引起部分用風(fēng)地點無風(fēng)(5)引起了最多的5次事故,反映出員工對于通風(fēng)知識的缺乏;另外,在7起事故中因沒有設(shè)計或設(shè)計了不合理的通風(fēng)系統(tǒng),或因在巷道貫通時沒有及時調(diào)整風(fēng)路(2),而導(dǎo)致巷道貫通后通風(fēng)系統(tǒng)的紊亂。分析造成巷道堵塞的原因發(fā)現(xiàn),員工對巷道堵塞的危險性認(rèn)識不足是導(dǎo)致未制定或未要求執(zhí)行巷道維護管理相關(guān)規(guī)定(4),或是在巷道抽排水前未編制安全技術(shù)措施(1)的主要原因。分析造成瓦斯排放不當(dāng)?shù)脑虬l(fā)現(xiàn),采用“一風(fēng)吹”排瓦斯(6)和隨意開停局部通風(fēng)機(4)是引起瓦斯積聚的主要不安全動作原因,但究其根源,是未制定或未要求執(zhí)行瓦斯抽放措施相關(guān)規(guī)定及局部通風(fēng)機管理相關(guān)規(guī)定。分析造成瓦斯異常涌出的原因發(fā)現(xiàn),雖然瓦斯異常涌出是突發(fā)事件,但在實際事故中,早于事故之前已有明顯征兆,但被員工忽視,如在日常作業(yè)中經(jīng)常發(fā)現(xiàn)巷道發(fā)生沖擊地壓或瓦斯涌出異常而未采取措施,或是在高瓦斯礦井(或是低瓦斯礦井的高瓦斯區(qū)域)采掘,未進(jìn)行瓦斯提前抽放。分析造成密閉空間瓦斯積聚的原因發(fā)現(xiàn),預(yù)防密閉空間瓦斯積聚的對策應(yīng)從監(jiān)控密閉空間的瓦斯?jié)舛惹闆r及當(dāng)開采接近密閉空間時,采取有效的安全技術(shù)措施,避免密閉空間瓦斯涌出這兩個角度入手。在22起事故中,有12起事故礦井未監(jiān)控密閉空間的瓦斯?jié)舛惹闆r,10起事故礦井在采掘接近密閉空間時,未采取有效的安全技術(shù)措施等是出現(xiàn)較多的不安全動作原因。分析造成爆破瓦斯積聚的原因發(fā)現(xiàn),5起事故放炮前都未制定爆破作業(yè)說明書,3起事故放炮后未采取通風(fēng)措施、未等炮煙消散、未檢查瓦斯?jié)舛染突氐焦ぷ髅孀鳂I(yè),這說明爆破工和當(dāng)班管理人員均沒有認(rèn)識到編制爆破作業(yè)說明書和炮后檢查的重要性。分析瓦斯?jié)舛葯z查類的原因發(fā)現(xiàn),74%的事故中存在作業(yè)流程中缺少檢查瓦斯?jié)舛冗@一環(huán)節(jié),從而未能及時發(fā)現(xiàn)瓦斯?jié)舛瘸薜那闆r。在78起事故中存在“瓦檢員當(dāng)班作業(yè)前未檢查瓦斯?jié)舛取钡那闆r,63起事故“作業(yè)前未檢查瓦斯?jié)舛取?從物態(tài)上看,43起事故地點附近無瓦斯傳感器,32個事故礦井員工未攜帶便攜式瓦檢儀,29個礦井瓦斯監(jiān)控系統(tǒng)損壞,因而影響了瓦斯檢查工作。上述原因從根本上來說,是事故礦井員工未能理解按規(guī)定檢查瓦斯的重要性造成的。反映在安全管理體系缺欠上,有54個事故礦井未配備足夠的瓦檢員,47個礦井在安全檢查制度中未明確要求需要檢查井下員工便攜式瓦檢儀佩戴情況等。(6)給出了瓦斯爆炸事故原因分析結(jié)果的應(yīng)用建議。對于單起事故原因分析結(jié)果,可以用于案例教學(xué)。對于事故原因統(tǒng)計的應(yīng)用,由于本文分析統(tǒng)計得到了一段時間內(nèi)引起瓦斯爆炸事故的各類原因,因而可以通過對各類原因的安全檢查,以檢驗生產(chǎn)礦井是否有效預(yù)防以往事故發(fā)生的原因;也可以了解事故中高頻次的原因類型、或可能被遺漏的原因類型,從而可以采取針對性的預(yù)防措施。
[Abstract]:The cause of the accident analysis is the basis of accident prevention. In recent years, coal serious gas explosion accidents in coal mine accidents accounted for a growing proportion of accidents, deaths caused by the high number and case analysis in this paper studies the reasons why scholars of the gas explosion accidents in coal mine underground, discovered the reason analysis focused on the accident is not safe and unsafe state action directly cause, reason of personal habits and management system causes less involved directly the deeper reason behind, and in the study of employee safety action, only consider the front-line team staff illegal action, consider the problem of management staff less unsafe action and other reasons. From the perspective of accident prevention, as far as possible a comprehensive analysis of reasons and present the accident, individuals and organizations etc. The reason, can be more comprehensive, effective for the present and future accident prevention work of the starting point, thinking or focus, as well as for staff training to provide guidance and reference. To achieve the research objectives, the accident caused the "2-4" model as the theoretical basis, research the reasons of gas explosion accidents and analysis method. Select the 2005-2014 occurred 105 serious gas explosion accident was analyzed. First, the accident occurred from the underground location, the time of the accident, the death toll, the mine gas level, mine ownership information and other aspects of the explosion on the 2005-2014 years of serious gas accidents due to factors of statistical analysis; second, from two angle of ignition and gas accumulation are analyzed in the safe movement of the cause of the accident, unsafe state, habitual behavior and safety management system. Due to a variety of reasons; finally, simple suggestions the cause of the accident analysis results in gas explosion accident prevention application method, get the following conclusions: (1) presents a method for the analysis on employee behavior as the starting point of the accident. The accident causing the "2-4" model is a theoretical model for practical application in the accident analysis, this paper proposes a 7 step analysis method, including (1) cutting organization; (2) after the accident analysis; (3) identify accident employees unsafe action; (4) analysis of unsafe state reasons; (5) discuss the causes of habitual behavior; (6) analysis safety management system defect reason; (7) analysis of the cause of the accident and its influence on the induction of the accident. (2) has recently been extraordinarily serious coal mine gas explosion accidents due to factors caused by law. 105 coal mine occurred in the 2005-2014 years of serious gas explosion accident The factors for statistical analysis found that with improving the level of safety management, shooting flames and sparks, or man-made ventilation management problems are gradually being resolved, the gas explosion physical process to more difficult to prevent, and more confined space gas accumulation and heat radiation, the reason for the change of impact friction sparks (3. The reason of causing) ignition sources and gas accumulation in the "accident" (see Appendix C). Through various reasons analysis of samples of accidents, according to the causes of the frequency, the gas explosion caused by the accident causes of "map". (4) have all kinds of reasons and entrainment of gas explosion fire starting point the accident causes: shooting flames found sealing and explosives and blasting equipment management is caused by two reasons most of the shooting flames. In addition, there are 36 accidents did not organize professional blasting work Training, 37 mine accidents occurred in daily operation command, neglect, condone illegal shooting behavior of workers, 38 mine accidents before blasting is not established or not required to execute the blasting operation instructions, these reasons prompted the formation of habitual peccancy blasters blasting behavior. Analysis of the causes of electric spark, the operation of electrical equipment failure the explosion (17), electrical equipment maintenance charged (9) is the main reason of accidents caused by unsafe action directly.17 unsafe state reasons there are 16 kinds of electrical equipment which belongs to the electric coal drill blasting, cable joint Ming (11) up to 41, mine accidents in 36 mine power supply is not installed advanced atresia and cut off the power supply control equipment that mine accidents general lack of awareness of power supply locking effect. In addition, due to lack of mine accidents of the electrical equipment and cable maintenance (38), explosion-proof electrical equipment whole life The use and management of life cycle (21), maintenance of electrical equipment ledger (19) and other related provisions, leads to a large number of live maintenance safety action and loss of critical electrical equipment. Analysis of the causes of fire and heat radiation, most accidents because not regularly check the integrity of the closed and air leakage, did not take prevention of air leakage in goaf measures (7), there is a long-term coal spontaneous combustion or the presence of fire did not take a warning for fire prevention measures for underground (6) and closed (7), ignore the damage of goaf roof water temperature rise, such as spontaneous combustion (6) signs of insecurity caused by the action of another. In 13 cases, only 3 accidents of mine goaf is not installed or the temperature detection alarm system and fire prevention system, that is not mine accident engineering and technical means are not in place, but the management is not implemented. Analysis of the causes of friction spark hair Now, for the prevention of friction spark impact, to avoid the collision of the direct operation of metal equipment, pay attention to the installation position of electrical and mechanical equipment, and maintenance management, especially the spare mechanical and electrical equipment integrity, and the importance of roof management in three aspects. At the same time, should emphasize the friction spark impact may occur in the staff training in (8). (5) the gas explosion accident caused by various reasons and laws of gas accumulation: analysis of causes of mine caused the insufficiency of air supply, direct management staff and even mine management staff is mainly caused by the insufficiency of air supply in the decision of mine. Mine management staff due to the lack of related knowledge of mine ventilation lead mine, unauthorized outage (8), without the use of mechanical ventilation (7), super layer mining (6) or (3) ultra ability mining occurred frequently, which leads to the insufficiency of air supply. The analysis result of mine local ventilation Found the reasons for the confusion management, the tunneling working surface without the use of local fan (9), local fan installation location error cause wind circulation (8) is mainly caused by the unsafe action of effective working face air insufficient; 43 accidents in the main unsafe state involving three, 30 times the with the local fan, and the air duct on the 15, the other 5 and ventilation structures; accordingly, reflecting the mine accidents more workers lack such as local fan causes and harm of pull wind circulation (15), the harm at local ventilator stop (8) and other safety knowledge; at the same time ventilation area common failing to fulfil its responsibility, local fan installation, use, management (16), hairdryer use, inspection, maintenance and management (15) and other relevant provisions also exist many shortcomings. By analyzing the reasons that ventilation system is not reasonable, miningventilation The error caused by partial structures set up with the wind site wind (5) caused the 5 accidents, reflecting the lack of knowledge of the staff for the ventilation; in addition, in 7 cases with no ventilation system design or design unreasonable, or because there is no in the roadway through the timely adjustment of wind path (2). Due to the roadway through the ventilation system. The disorder caused by tunnel blockage causes analysis of dangerous roadway congestion, employees lack the understanding is the result of not developed or not required to implement the relevant provisions of the management of roadway maintenance (4), or in the tunnel pumping not prepare safety measures before drainage (1) the main reason analysis. The gas emission caused by the improper reason that the cancellation of "gas (6) and random stop local fan (4) is the main cause of unsafe action of gas accumulation, but the reason is not developed or not required to perform gas drainage The relevant provisions of the relevant provisions and measures of local ventilator management. Analyze the causes of abnormal gas emission is found, although unusual gas emission is the unexpected events, but in the actual accident, as early as before the accident has obvious signs, but the staff was ignored, such as in daily operation are often found in roadway rockburst or abnormal gas emission not to take measures, or in the high gas mine (or high gas area of low gas coal mine mining, gas) without advance drainage. Find the reason analysis of the causes of the confined space of gas accumulation, gas concentration and prevention of gas accumulation in the confined space monitoring and Countermeasures should be confined space when mining near the enclosed space, take safe and effective technical measures, avoid starting from this two aspects of the confined space gas. In 22 cases, there were 12 accidents in mine monitoring confined space gas concentration. 10 mine accident situation, close to the confined space in the mining, did not take effective safety measures is more unsafe action. Cause analysis of blasting gas accumulation, 5 accidents are not set before shooting of blasting operation manual, 3 accidents after blasting without proper ventilation measures, without guns the smoke, did not check the gas concentration on the back of the working face, which shows the importance of inspection and management personnel are on duty blasting work does not recognize the preparation instructions and after blasting gun. The causes of the gas concentration inspection found that the lack of check gas concentration in this part of the process of the existence of 74% accidents, and failed to timely found that the gas concentration overrun. In 78 cases there are "Fireboss on duty did not check the gas concentration before operation, 63" accident "operation before the inspection of gas concentration"; From the physical point of view, near the 43 accident locations without gas sensor, 32 accidents of mine staff does not carry a portable gas detection instrument, damaged 29 mine gas monitoring system, thus affecting the gas inspection work. The reason basically is the accident of mine staff failed to understand the importance of the inspection of gas in accordance with the provisions of the reflect caused. In the safety management system deficiencies, there are 54 accidents of mine Fireboss not equipped with enough, 47 in the coal mine safety inspection system does not explicitly require the employees to check the portable gas detection instrument wear. (6) suggested that the application of a reason of gas explosion accident analysis results. For single accident reason analysis the results can be used for the application of case teaching. For the cause of the accident statistics, due to the statistical analysis has been the cause of all kinds of gas explosion accident in a period of time, can be based on Safety checks for various reasons are used to check whether the production well is effective in preventing the causes of past accidents, and to understand the causes of the accidents in high frequency, or the types of causes that may be missed, so that we can take specific preventive measures.

【學(xué)位授予單位】：中國礦業(yè)大學(xué)(北京)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：TD712.7

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