从问责调查到问题调查——基于系统论和系统安全理论的思考与建议

生产安全事故调查处理是安全生产工作的一项重要内容，事故调查的政策和方法等的制度创新对完善我国安全生产工作的体制机制有很大意义。针对当前我国安全生产总体形势和事故调查处理的工作现状，采用对照评估的方法，分析了近三年来我国特大事故发生的态势和原因，总结了事故发生的基本规律和共性问题，基于系统安全的思想，认为安全是系统整体属性，系统脆弱性是导致重特大事故风险和严重损失的主要原因，不应简单把事故仅仅归咎于某些人或某件事的责任。据此，进一步分析生产安全事故调查处理的利弊得失，提出在现有基础上，进一步改革创新生产安全事故调查处理制度，应逐步实现从问责调查向问题调查的转变，并对如何修改《生产安全事故报告和调查处理条例》（国务院令第493号）提出了六条具体建议。

From accountability investigation to problem investigation-thinking and suggestions based on system theory and system safety theory

The investigation and disposition of work safety accidents is an important part of work safety, and the institutional innovation on policies and methods of accident investigation has great significance to improve the system and mechanism of work safety in our country. Aiming at the overall situation of work safety and the current situation of accident investigation and disposition in our country, the situation and causes of extraordinarily serious accidents occurred in China in the past three years were analyzed by using the method of contrast evaluation, and the basic rules and common problems of the accidents were summarized. Based on the idea of system safety, it was considered that safety is the overall attribute of system, and the system vulnerability is the main cause of major accident risks and severe losses, the accident should be simply blamed to the responsibility of someone or something only. On this basis, the advantages and disadvantages of investigation and disposition of work safety accidents were analyzed further. It was proposed to reform and innovate the investigation and disposition system of work safety accidents based on the existing foundation, and gradually realize the transition from accountability investigation to problem investigation. Six specific suggestions on how to revise "Regulations on the Reporting, Investigation and Disposition of Work Safety Accidents" (State Council Decree No. 493) were put forward.