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基于根因分析与图论的事故预防理论模型

Theoretical Model for Accident Prevention Based on Root Cause Analysis With Graph Theory.

作者信息

Molan Gregor, Molan Marija

机构信息

Comtrade, Letališka Cesta 29, Ljubljana, Slovenia.

University Medical Centre Ljubljana, Institute of Occupational, Traffic and Sports Medicine, Poljanski Nasip 58, Ljubljana, Slovenia.

出版信息

Saf Health Work. 2021 Mar;12(1):42-50. doi: 10.1016/j.shaw.2020.09.004. Epub 2020 Sep 17.

DOI:10.1016/j.shaw.2020.09.004
PMID:33732528
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC7940444/
Abstract

INTRODUCTION

Despite huge investments in new technology and transportation infrastructure, terrible accidents still remain a reality of traffic.

METHODS

Severe traffic accidents were analyzed from four prevailing modes of today's transportations: sea, air, railway, and road. Main root causes of all four accidents were defined with implementation of the approach, based on Flanagan's critical incident technique. In accordance with Molan's Availability Humanization model (AH model), possible preventive or humanization interventions were defined with the focus on technology, environment, organization, and human factors.

RESULTS

According to our analyses, there are significant similarities between accidents. Root causes of accidents, human behavioral patterns, and possible humanization measures were presented with rooted graphs. It is possible to create a generalized model graph, which is similar to rooted graphs, for identification of possible humanization measures, intended to prevent similar accidents in the future. Majority of proposed humanization interventions are focused on organization. Organizational interventions are effective in assurance of adequate and safe behavior.

CONCLUSIONS

Formalization of root cause analysis with rooted graphs in a model offers possibility for implementation of presented methods in analysis of particular events. Implementation of proposed humanization measures in a particular analyzed situation is the basis for creation of safety culture.

摘要

引言

尽管在新技术和交通基础设施方面投入巨大，但严重交通事故仍是交通领域的现实问题。

方法

从当今四种主要运输方式（海运、空运、铁路和公路）分析严重交通事故。基于弗拉纳根关键事件技术，采用该方法确定了这四种事故的主要根本原因。根据莫兰的可用性人性化模型（AH模型），确定了可能的预防或人性化干预措施，重点关注技术、环境、组织和人为因素。

结果

根据我们的分析，事故之间存在显著相似性。用根图展示了事故的根本原因、人类行为模式和可能的人性化措施。可以创建一个类似于根图的通用模型图，用于识别旨在预防未来类似事故的可能人性化措施。大多数提议的人性化干预措施集中在组织方面。组织干预对于确保适当和安全的行为是有效的。

结论

在模型中用根图对根本原因分析进行形式化，为在特定事件分析中应用所提出的方法提供了可能性。在特定分析情况下实施提议的人性化措施是创建安全文化的基础。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/f6205866b1b8/gr7.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/0dd944896fde/gr1.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/2a5720b2ddc7/gr2.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/33db24c330fe/gr3.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/800ec2a9003a/gr4.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/fc4245e1d0f4/gr5.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/f7886cf923eb/gr6.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/f6205866b1b8/gr7.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/0dd944896fde/gr1.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/2a5720b2ddc7/gr2.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/33db24c330fe/gr3.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/800ec2a9003a/gr4.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/fc4245e1d0f4/gr5.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/f7886cf923eb/gr6.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/4976/7940444/f6205866b1b8/gr7.jpg

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