Underwood Peter, Waterson Patrick
Loughborough Design School, Loughborough University, Loughborough, Leicestershire LE11 3TU, UK.
Loughborough Design School, Loughborough University, Loughborough, Leicestershire LE11 3TU, UK.
Accid Anal Prev. 2014 Jul;68:75-94. doi: 10.1016/j.aap.2013.07.027. Epub 2013 Aug 1.
The Swiss Cheese Model (SCM) is the most popular accident causation model and is widely used throughout various industries. A debate exists in the research literature over whether the SCM remains a viable tool for accident analysis. Critics of the model suggest that it provides a sequential, oversimplified view of accidents. Conversely, proponents suggest that it embodies the concepts of systems theory, as per the contemporary systemic analysis techniques. The aim of this paper was to consider whether the SCM can provide a systems thinking approach and remain a viable option for accident analysis. To achieve this, the train derailment at Grayrigg was analysed with an SCM-based model (the ATSB accident investigation model) and two systemic accident analysis methods (AcciMap and STAMP). The analysis outputs and usage of the techniques were compared. The findings of the study showed that each model applied the systems thinking approach. However, the ATSB model and AcciMap graphically presented their findings in a more succinct manner, whereas STAMP more clearly embodied the concepts of systems theory. The study suggests that, whilst the selection of an analysis method is subject to trade-offs that practitioners and researchers must make, the SCM remains a viable model for accident analysis.
瑞士奶酪模型（SCM）是最流行的事故因果关系模型，在各个行业中广泛使用。研究文献中存在关于SCM是否仍然是事故分析的可行工具的争论。该模型的批评者认为，它提供了一种对事故的顺序性、过于简化的观点。相反，支持者认为，根据当代系统分析技术，它体现了系统理论的概念。本文的目的是考虑SCM是否可以提供一种系统思维方法，并仍然是事故分析的可行选择。为了实现这一目标，使用基于SCM的模型（澳大利亚运输安全局事故调查模型）以及两种系统事故分析方法（AcciMap和STAMP）对格雷里格火车脱轨事故进行了分析。对这些技术的分析输出和使用情况进行了比较。研究结果表明，每个模型都应用了系统思维方法。然而，澳大利亚运输安全局模型和AcciMap以更简洁的方式以图形方式呈现了它们的发现，而STAMP更清楚地体现了系统理论的概念。该研究表明，虽然分析方法的选择需要从业者和研究人员进行权衡，但SCM仍然是事故分析的可行模型。
