Applying systems thinking to analyze and learn from events

Major accidents keep occurring that seem preventable and that have similar systemic causes. Too often, we fail to learn from the past and make inadequate changes in response to losses. Examining the assumptions and paradigms underlying safety engineering may help identify the problem. The assumption...

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Vydáno v:Safety science Ročník 49; číslo 1; s. 55 - 64
Hlavní autor: Leveson, Nancy G.
Médium: Journal Article
Jazyk:angličtina
Vydáno: Elsevier India Pvt Ltd 2011
Témata:
Accident model
Causal factors
Hazard analysis
Operator error
Safety versus reliability
Causal factors
Safety versus reliability
Operator error
Accident model
Hazard analysis
ISSN:0925-7535, 1879-1042
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Shrnutí:Major accidents keep occurring that seem preventable and that have similar systemic causes. Too often, we fail to learn from the past and make inadequate changes in response to losses. Examining the assumptions and paradigms underlying safety engineering may help identify the problem. The assumptions questioned in this paper involve four different areas: definitions of safety and its relationship to reliability, accident causality models, retrospective vs. prospective analysis, and operator error. Alternatives based on systems thinking are proposed.
Bibliografie:ObjectType-Article-1
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content type line 23
ISSN:0925-7535
1879-1042
DOI:10.1016/j.ssci.2009.12.021