近年來因多次發生機械操作訓練及維修失慎導致人員及機械的損傷及損壞事件，而此刻正積極進行組織調整，操作及維修新機械的人員培訓，在工作份量不斷激增的情形下，若人員不能運用作業風險管理機制，預知工作內容所產生之威脅與疏失進而避讓危害，讓錯誤程序一再重複發生，終究將肇致無法挽回的重大傷亡事件。 本研究主要目的，是以結合作業風險管理之概念，檢討目前實施各維修前風險管控流程及實際執行故障排除方法可能的疏漏，所謂「事前防範重於事後處理」的觀念固然重要，但對於檢修過程中可能產生之威脅與疏失風險因子，仍甚少探討。 本文將透過歷次機械操作及維修人員肇生之危安事件進行案例探討，發展出檢修中可能產生的潛存風險，提供機械操作及維修人員事前討論及危機狀況發生時之應變作為，期待在有限資源，透過維修人員於檢修中發掘各種可能存在之威脅與疏失風險，並運用不斷發掘、管控、排除，以達「零危安」之目標。 In recent years, the Company has numerous maintenance mishaps which cause personnel injury and equipment damage, and now the Company are actively adjusting organization and training mechanics for the new equipment maintenance. In the case of an increasing workload, if the supervisor cannot use the risk management technique to predict the threats and errors in the work and avoid the damage, so that the wrong procedure repeated, and eventually will be irreversible heavy casualties. The purpose of this thesis was to combine the concept of risk management and reviewed the possible omissions in Company''s current pre-maintenance risk management process and troubleshooting methods. The idea of "Prevention is better than cure" is important, but there is little discussion about the possible threats and errors risk factors in the maintenance procedure. This thesis was conducted a case study of the Company''s mechanic mishaps history to develop the potential risk might occur in the maintenance, to provide maintenance personnel pre-discussion and strategy for crisis occurred. Within limited resources, through the maintenance personnel to identify a variety of possible risks in the maintenance procedures, and use continuous identification, control, and reduction achieve "zero risk" target.
