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事故与未遂事故的成因:文献综述、英国铁路领域的实证检验及其对其他行业的启示

Accident versus near miss causation: a critical review of the literature, an empirical test in the UK railway domain, and their implications for other sectors.

作者信息

Wright Linda, van der Schaaf Tjerk

机构信息

Prorail, De Inktpot, Moreelsepark 3, 3511 EP Utrecht, Postbus 2038, Utrecht 3500 GA, The Netherlands.

出版信息

J Hazard Mater. 2004 Jul 26;111(1-3):105-10. doi: 10.1016/j.jhazmat.2004.02.049.

Abstract

An essential assumption for the usefulness of basing accident prevention measures on minor incidents is the common cause hypothesis: that causal pathways of near misses are similar to those of actual accidents (such as injuries and damages). The idea of a common cause hypothesis was originally proposed by Heinrich in his seminal book "Industrial Accident Prevention" [McGraw-Hill, New York]. In this paper, it is argued that the hypothesis of similarity of causes for major and minor accidents has become confounded with the interdependence of the ratio relationship between severity and frequency. This confounded view of the hypothesis has led to invalid tests of the hypothesis and erroneous conclusions. The evidence from various studies is examined and it is concluded that the hypothesis has not been properly understood or tested. Consequently, such a proper test was carried out using data from the UK railways which were analysed using the confidential incident reporting and analysis system (CIRAS) 21 cause taxonomy. The results provide qualified support for the common cause hypothesis with only three out of the 21 types of causes having significantly different proportions for the three consequence levels investigated: 'injury & fatality', 'damage' and 'near miss'.

摘要

将事故预防措施基于小事故的有效性的一个基本假设是共同原因假说

即未遂事故的因果路径与实际事故(如伤害和损害)的因果路径相似。共同原因假说的概念最初由海因里希在他的开创性著作《工业事故预防》(麦格劳 - 希尔出版社,纽约)中提出。在本文中,有人认为重大事故和小事故原因相似的假说已与严重程度和频率之间比率关系的相互依存性混淆。这种对假说的混淆观点导致了对该假说的无效检验和错误结论。对来自各种研究的证据进行了审查,并得出结论认为该假说尚未得到正确理解或检验。因此,使用来自英国铁路的数据进行了这样一项恰当的检验,这些数据是通过机密事件报告与分析系统(CIRAS)的21种原因分类法进行分析的。结果为共同原因假说提供了有限的支持,在所调查的三个后果级别“伤害与死亡”、“损害”和“未遂事故”中,21种原因类型中只有三种的比例存在显著差异。

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