Goode Natassia, Read Gemma J M, van Mulken Michelle R H, Clacy Amanda, Salmon Paul M
Faculty of Arts, Business and Law, Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast Maroochydore, QLD, Australia.
Front Psychol. 2016 Dec 23;7:1974. doi: 10.3389/fpsyg.2016.01974. eCollection 2016.
Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the "broken components." However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system.
系统思维方法的倡导者认为，事故预防策略应侧重于改革系统，而不是修复“故障部件”。然而，对于组织如何将事故数据转化为针对事故系统性原因的预防策略，几乎没有相关指导。本文描述并评估了一系列针对多起事故分析而设计的系统思维预防策略。该研究在澳大利亚的户外主导活动（LOA）领域进行，该领域提供如峡谷探险、海上皮划艇、攀岩和露营等有监督或指导的户外活动。设计过程包括与从业者举办研讨会，并聚焦于使用拉斯穆森的事故地图（AcciMap）技术分析的事故数据。基于事故系统性原因的一系列反思点被用于指导设计过程，事故地图技术被用于呈现预防策略及其相互关系，从而创建了预防地图（PreventiMaps）。对预防地图的评估表明，所有地图都纳入了系统思维方法的核心原则，并且许多地图提出了改善户外主导活动系统垂直整合的预防策略。然而，大多数地图未能解决工作实践的迁移和风险控制的侵蚀问题。总体而言，研究结果表明，设计过程在帮助从业者将事故数据转化为针对事故系统性原因的预防策略方面取得了部分成功；需要对设计过程进行完善，以使从业者更加专注于设计监测和反馈机制，以支持系统高层的决策。
