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本文从开滦局 L 矿1989年在同一个提升井发生的两起罐笼“切人”事故案例中悟出了四点不易显露的事故原因。如忽视对井口把钩工岗位安全教育;分析和处理事故时不对照《煤矿安全规程》或本矿的《规定》找出事故的本质原因(第一次事故后,仍未按照《规程》和《规定》加装或完善提升信号闭锁装量,致使罐笼“切人”事故重复发生);分析事故时忽视了从那些比较隐蔽的间接原因中找出导致两起同类事故的根源。文中还根据这两起事故的原因写出了“直接原因——间接原因——根本(基础)原因”的事故链。指出,只要将间接原因中的任何一个去掉,都可以防止事故发生,但若将直接原因去掉,则不能避免事故发生。
This article from the Kailuan Bureau L mine in 1989 in the same upgrade wells occurred in two cases of cage cut “accidental cases realized four not easy to reveal the cause of the accident. Such as neglecting safety education on hooked workers at the wellhead; finding out the essential cause of the accident when analyzing and handling the accidents without reference to the ”Coal Mine Safety Regulations“ or the ”Regulations“ of the mine (after the first accident, the ” “Provisions” to install or improve the signal blocking device to upgrade, resulting in cage “cut” incident repeated); analysis of the accident ignores the more indirect cause of those covert to find the cause of two similar incidents. The article also based on the causes of these two accidents to write the “direct cause - indirect causes - fundamental (basic) causes” accident chain. Pointed out that as long as any one of the indirect causes removed, can prevent the accident, but if the direct cause is removed, you can not avoid the accident.