【摘要】 科学界定事故原因既是问责的基础和依据，也是回应公众期待的重要途径，更是公共部门开展危机学习的重要环节，是预防危机的关键因素。基于事故人因分析与分类系统(HFACS)模型，本文从组织影响、不安全的监督、不安全行为的前提以及不安全行为等4个层级对我国2007-2020年53起特别重大事故调查报告中的人为原因进行了研究，通过文本编码统计、关联性分析及链式中介效应检验，识别每一层级的主要人为因素，揭示各层级致因类别的递进关系，进而验证不同层级可能存在的人为因素影响链条。本文最后尝试提出一个中国特大事故人因逻辑演化的一般性解释框架，并认为加强特别重大事故预防的途径在于切断人为因素逻辑链和加强组织层面管理，从源头上减少每一层级的人为错误。更多还原

【Abstract】 Scientifically defining the causes of production safety accidents is both the foundation and basis for accountability and an important way to respond to public expectations，as well as an important part of crisis learning in the public sector and a key factor in crisis prevention.According to the Human Factors Analysis and Classification System(HFACS) model，this paper examines the human factors in the investigation reports of 53 mass serious safety accidents in China from 2007 to 2020 at four levels：organizational influence，unsafe supervision，preconditions for unsafe acts，and unsafe acts.Specifically，through text coding，Chi-square analyses，Lambda，and serial mediation effect testing，the main human factors in each level were identified，with the progressive relationship of the causative categories in each level revealed，and then the possible serial mediation effects of human factors in different levels were verified.This paper proposes a general explanatory framework for the transmission of human factors of mass serious safety accidents in China.The way to strengthen the prevention of mass serious safety accidents is to break the human factor logic chain and strengthen the management at the organizational level to reduce human errors at each level from the source.更多还原