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你发现的并不总是你能解决的——决定补救措施建议的因素除了事故原因还有很多方面。

What you find is not always what you fix--how other aspects than causes of accidents decide recommendations for remedial actions.

机构信息

Linköping University, Department of Science and Technology, Campus Norrköping, 601 74 Norrköping, Sweden.

出版信息

Accid Anal Prev. 2010 Nov;42(6):2132-9. doi: 10.1016/j.aap.2010.07.003. Epub 2010 Jul 29.

Abstract

In accident investigation, the ideal is often to follow the principle "what-you-find-is-what-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.

摘要

在事故调查中,理想情况通常是遵循“所见即所修”原则,这一理想反映出调查应该是一个理性的过程,首先要确定原因,然后采取补救措施来解决这些原因。然而,先前的研究已经确定了导致偏离这一理想情况的认知和政治偏见。然而,有些令人惊讶的是,尽管现代事故模型中经常强调相同的因素,但这些因素并没有以递归的方式被感知,以反映它们如何影响事故调查本身的过程。这些因素比理论中经常强调的认知和政治偏见更为广泛。我们在这项研究中的目的是揭示影响事故调查实践的限制因素,这些限制因素会导致调查偏离或接近“所见即所修”的理想情况。我们对来自瑞典不同领域的 22 名事故调查员进行了定性访谈研究。我们发现了一系列导致调查偏离理想情况的因素,其中大多数因素更类似于组织事故中涉及的因素,而不是反映有缺陷的思维。调查的一个特别局限性是,许多调查在“可预防原因”的层面上停止了分析,在这个层面上,可以找到目前实际可行的补救措施。这可能会限制利用调查来了解事故原因的“全貌”,并将其作为进一步采取补救措施的基础的有效性。

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