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复杂事故致因理论:运用 AcciMap 识别 11 起灾难中的系统思维原则

Complexity theory in accident causation: using AcciMap to identify the systems thinking tenets in 11 catastrophes.

机构信息

Faculty of Arts, Business and Law, Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Sippy Downs, Australia.

Faculty of Engineering and Physical Sciences, Transportation Research Group, University of Southampton, Southampton, United Kingdom.

出版信息

Ergonomics. 2021 Jul;64(7):821-838. doi: 10.1080/00140139.2020.1869321. Epub 2021 Feb 1.

DOI:10.1080/00140139.2020.1869321
PMID:33357083
Abstract

The quest to explain and understand the cause of accidents is both ever-present and ongoing amongst the safety science community. In an attempt to advance the theory and science of accident causation, researchers have recently formalised a set of '15 systems thinking tenets' that cover the conditions and characteristics of work systems that are believed to contribute to the cause of accidents. The purpose of this study was to attempt to identify the systems thinking tenets across a range of different systems and accidents using the Accident Mapping (AcciMap) method. The findings suggest that the tenets can be attributed to play a role in accident causation, however as a result of this process, the capability of AcciMap has been brought into question. Implications and directions for future research are described. : This study is an extension of previous work that suggested there was a need to test for the 'systems thinking tenets of accident causation' in a multi-incident dataset. We used AcciMap to evaluate whether it has the capability to support ongoing accident analysis activities in ergonomics research.

摘要

在安全科学领域,解释和理解事故原因的探索一直存在且不断进行。为了推进事故致因理论和科学的发展,研究人员最近确定了一套“15 条系统思维原则”,涵盖了被认为导致事故的工作系统的条件和特征。本研究旨在使用事故映射(AcciMap)方法,在一系列不同的系统和事故中尝试识别系统思维原则。研究结果表明,这些原则可能在事故致因中发挥作用,然而,由于这一过程,AcciMap 的能力受到了质疑。本文描述了对未来研究的影响和方向。本研究是之前研究的延伸,该研究表明需要在多事件数据集内测试“事故致因的系统思维原则”。我们使用 AcciMap 来评估其是否有能力支持在人机工程学研究中的持续事故分析活动。

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