目前煤矿重特大事故频发的局面没有完全扭转，安全形势依然严峻。究其原因，组织管理不善所致的人误行为是导致煤矿事故发生的症结所在。因此，本文就煤矿人误事故展开组织定向研究。 首先对人误的概念、分类进行了探讨，并由此提出组织人误的概念和分类；在此基础上，应用编码故障树事故分析方法，对我国26起特别重大煤矿事故进行了事故/事件再分析，统计结果显示了煤矿人误及组织人误的分布规律。 其次，引入宏观和微观动态组织人误及静态组织人误的概念，并探讨了组织人误的形成机理；基于复杂社会技术系统观点，分析得出个人、组织、环境、技术四维度煤矿组织人误形成因子关联分析层次表；分析陕西某煤矿77起事故，并将统计结果进行灰色关联分析。分析结果显示，组织人误的根源主要是决策者个人的技能和责任心以及组织监管和组织文化四个方面存在缺陷；发生频次最高的管理者个人决策因子的影响因素众多，没有显著的差距，需要管理者提高其综合素质。 再次，在对事故和组织人误形成过程分析的基础上，结合安全管理学、认知心理学、组织行为学及事故致因理论，分析了煤矿组织人误事故致因，并通过案例验证，最终确定了三级管理层动态决策致因模型，对事故分析、原因调查及事故预防具有一定的理论参考价值。 最后，基于系统工程理论，构建了由社会环境基础系统和企业内控系统构成的组织人误控制系统模型，并探讨了安全文化、激励机制、非正式组织等对控制组织人误的作用及优化途径，为企业和政府提供了安全管理决策的依据和参考。

At present, the coal mine fatal accidents have occurred frequently in my country, and the safety situation still has been grim. The key is organizational management failures. Therefore, the paper has focused on the organization factors of human errors in the coal mine accidents. Firstly, the paper has discussed the concept and the sort of human errors. Then, the concept and the sort of the oranization errors were put forward. In according to, the Coded Fault Tree Methodology was used for analyzing of 26 coal mine fatal accidents based on the basal theories of organization errors. The result showed the distributing rule of the human errors and the oranization errors. Secondly, the paper has intruduced the concept of macroscopic or microcosmic dynamic state orangization errors and static state orangization errors, then discussed the formation mechanism of organization errors. Based on the view of the complicated socio-technical system, the paper has educed the table of the Organization Errors Shape Factors from individuals, organizations, environmental and technical points of view. 77 accidents of Shaanxi’s one coal mine were analysed, then the result was analysed using Grey Relational Analysis. The result was that the root of the organization errors was mostly the failures of decision-makers’ skills and responsibility, organizational surpervising and culture. The factor of Managers’ decision-making that occured the most frequently had many shape factors, and these factors had no distinct difference, therefore, the managers needed to improve theirselves’ whole diathesis. Thirdly, the paper has discussed the accident-causing theories and constructed the Accident-causing of Dynamic Decision-making among Three Class of Managers model. The process has combined with the Safety Management, Cognitive Psychology and Organization Behavior and so on. This model has some theoretical reference value to accident analysis, lookuping reason and preventing accidents. Finally, the paper has constructed the Integration System of Controlling Organization Errors that composed of Society Environment Basic System and Corporation Inside Controlling System and based on the systems engineering theory. Moreover, the paper has discussed the function and optimizing approaches of the safety culture, incentive mechanism and informal organization.