What-You-Look-For-Is-What-You-Find – The consequences of underlying accident models in eight accident investigation manuals

Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of what we currently know – or assume – about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. In this paper we examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, we focus on accident models and in particular the assumptions about how different factors interact to cause – or prevent – accidents, i.e., the accident “mechanisms”. Secondly, we focus on the scope in the sense of the factors (or factor domains) that are considered in the models – for instance (hu)man, technology, and organization (MTO). Thirdly, we focus on the system of investigation or the activities that together constitute an accident investigation project/process. We found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the ‘What-You-Look-For-Is-What-You-Find’ or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called ‘What-You-Find-Is-What-You-Fix’ or WYFIWYF principle.     

Coordinability and consistency: Application of systems theory to accident causation and prevention

Recent works in the safety literature report several fruitful attempts to introduce mathematically rigorous results from systems and control theory to bear upon accident prevention and system safety. Previously, we discussed the implications on safety of the systems theoretic principles of coordinability and consistency, and we identified the lack of coordinability and/or consistency as fundamental failure modes in hierarchical multilevel systems. In this work, we further develop system safety analysis techniques based on these principles. We demonstrate that these principles not only provide a domain-independent vocabulary for expressing the results of post-mortem accident analyses, but they can also be applied to guide design and operational choices for accident prevention and system safety. We develop these ideas with the help of an illustrative case study. This case study represents a broad class of systems where operational policies and procedures of individual stakeholders in the system interact with physical processes such that new system behaviors emerge, and unanticipated safety issues arise. We argue, and illustrate our arguments using this case study, that the coordinability and consistency principles can be developed to deliver a threefold impact on accident analysis and prevention: firstly, these principles provide domain-independent procedural templates and vocabulary for post-mortem accident analysis. Secondly, these principles provide theoretical safety specifications to be met during system design and operation. Finally, these safety specifications can precipitate the formulation of a series of questions directly related to safety-oriented choices in the design, operation, and control of systems.     

FDA事故致因模型在海上船舶碰撞事故安全管理中的运用研究

FDA事故致因模型从安全信息视角出发,将海上船舶碰撞事故发生的宏观与微观因素系统地结合在一起,以管理科学和技术科学为依据,构建海上船舶碰撞FDA事故致因模型,从微观到宏观即个体船只、海运企业、海事局3个层面进行安全信息视域下的事故致因分析,通过逻辑推导定位最佳的安全管理方位。研究结果表明:FDA事故致因模型由3条事故子链及1条事故主链构成,能够从微观到宏观完整表达海上船舶碰撞事故发生过程及机理;破坏3条FDA事故子链或FDA事故主链的形成即可有效地预防海上船舶碰撞事故的发生,对促进海上船舶航行安全管理水平的提高具有重要的理论与现实意义。     

基于能量流系统的事故致因与预防模型构建

为完善事故致因理论体系,论述并解析能量流系统定义,分析系统能量流流向, 构建基于能量流系统的事故致因概念模型,并从能量串发、发散、集中和混合四方面解 析其内涵。对能量流的聚集、耦合、转换、释放,以及意外释放能量的防控效果、破坏 强度和伤害程度等进行数学描述。基于此,构建基于能量流系统的事故预防概念模型, 并提炼减灾措施。研究结果明晰了事故发生的物理本质,从能量流系统的视角为事故致 因的定量分析或半定量半定性分析提供理论参考,并可为事故预防与控制提供理论指导 。     

基于熵理论的重大事故复杂链式演化机理及其建模

为完善重大事故演化的本质规律和探究事故后果累积放大原理,从安全物质学的视角提出事故链定义和形成机理,并解析其内涵;通过物质、能量和信息表征事故链演化过程的载体反映;基于物质流、能量流和信息流构建事故链式演化概念模型;基于熵理论和耗散结构理论论述事故阶段演化特性;在此基础上,提炼事故预防与控制策略框架。研究结果丰富了事故链式演化理论,可为事故预防与控制提供更深层次的理论基础。     

A new accident model for engineering safer systems

New technology is making fundamental changes in the etiology of accidents and is creating a need for changes in the explanatory mechanisms used. We need better and less subjective understanding of why accidents occur and how to prevent future ones. The most effective models will go beyond assigning blame and instead help engineers to learn as much as possible about all the factors involved, including those related to social and organizational structures. This paper presents a new accident model founded on basic systems theory concepts. The use of such a model provides a theoretical foundation for the introduction of unique new types of accident analysis, hazard analysis, accident prevention strategies including new approaches to designing for safety, risk assessment techniques, and approaches to designing performance monitoring and safety metrics.     

10种事故致因模型的对比研究

为了给事故致因模型的研究提供理论支持,为日常管理中事故致因模型的选用提供参考依据,从事故的影响对象、模型的组成和事故发生的路径3个维度对10种事故致因模型进行了对比分析。研究结果表明:事故致因模型对事故影响对象的涵盖越来越全面;事故致因模型的组成日趋全面,且趋于对模型中各模块给出清晰定义以能保证分析结果的准确性;故发生的路径描述由链式向系统网状发展;根据充分性和效率的需求对模块化模型和非模块化的模型进行选择。     

基于FDA事故致因模型的铁路行车安全管理研究

为了从安全信息视角深入分析铁路行车事故原因,基于信息学、管理科学和行为科学等相关理论知识,结合铁路行车事故致因原理,构建铁路行车FDA(Forecast-Decision-Action)事故致因模型.该模型由行车人员、铁路运输企业和国家铁路局3条事故致因子链和1条事故致因主链构成,进一步归纳总结出3条子事故域、1条总事...     

Occupational injury and accident research: A comprehensive review

In this paper, a comprehensive review of the concepts of occupational injury and accident causation and prevention is presented. Starting with hazard identification, the issues on risk assessment, accident causation, and intervention strategies are discussed progressively. The distinctiveness and overlaps in accident and injury research are highlighted. Both empirical research in terms of hypotheses tested and theoretical research such as accident causation models are compared and contrasted. Finally, based on the critical appraisal of the comprehensive review, future research directions on occupational injury research are delineated.     

LPG leakage and explosion accident analysis based on a new SAA method

The petrochemical industry has inherently high safety risks. On 5^th June 2017, a liquefied petroleum gas tanker in the storage and transportation department of Linyi Jinyu Petrochemical Co., Ltd. leaked during unloading, causing a major explosion and fire. Ten people were killed and nine were injured. To prevent the recurrence of similar accidents, a retrospective accident analysis was conducted using the system accident analysis method known as ‘24Model’. This analysis proved the coupling relationship between accident causes involving multiple organisations and multiple factors. The analysis results show that the five modules of maintenance and design, that is, loading and unloading valves, emergency training, management of subsidiaries and contractors, multi-level supervision, and task arrangement need to be checked from top to bottom by relevant organisations.In order to verify the reliability of 24Model analysis results, three SAA methods, namely STAMP, FRAM, AcciMap, were used to analyse the accident, and results obtained by the four methods were evaluated qualitatively and quantitatively. The results show that the output of 24Model is reliable and has a more understandable framework, which can be used as reference for the development of other linear accident cause models and application of system accident analysis methods to real applications.     

基于虚拟现实技术的事故分析方法

阐述了虚拟现实技术在民航安全方面的应用前景和重要意义 ,并应用于飞行事故分析。通过建立事故模型 ,笔者对飞行中相对应的人—机关系进行描述。这些关系对事故原因分析是十分重要的。在这个框架下实现了三维模型动画显示 ,并利用计算机多媒体技术 ,实现真实感图形动态显示和音效合成 ,虚拟环境和立体显示 ,展现亲历事故的真实效果     

国内外矿山事故预防与救护机制对比分析

简要介绍了印度、德国、美国、加拿大等国矿山事故预防与救护机制,与我国的矿山事故预防和救护机制进行了对比分析,指出我国矿山伤亡事故的严峻形势,提出了我国矿山事故预防与救护的建议,对减少矿山事故、发展矿山经济具有指导意义。     

System safety assessment using safety entropy

Safety assessment has a primary role in hazardous operations. Most studies on safety assessment focus on risk and accident modeling, in which safety is absent. These top-down methods are highly dependent on the occurred accidents to establish accidental scenarios, which may make the assessment approach lagging behind the evolving modern systems. Moreover, this “special to general” logic is scientifically suspect in safety assessment. There is a call for the development of safety assessment methods in the presence of system safety to complement risk-focused safety analysis. These methods should provide a framework based on a bottom-up approach to examine system safety from the operational perspective. This paper has attempted to provide a potential solution. In particular, a novel concept of safety entropy is proposed to integrate with The Functional Resonance Analysis Method (FRAM), which is used to form the qualitative understanding of a system. A formula consisted of safety entropy, functional conformability, and system complexity has been established to determine the spontaneity of the safety state-changing process. The proposed method is applied to the safety assessment of a propane feed-control system. The results show the applicability of the method. Nevertheless, the model still needs to be further improved to fulfill better support for safety-related decision problems.     

Accident analysis model based on Bayesian Network and Evidential Reasoning approach

In this paper, an accident analysis model is proposed to develop the cost-efficient safety measures for preventing accidents. The model comprises two parts. In the first part, a quantitative accident analysis model is built by integrating Human Factors Analysis and Classification System (HFACS) with Bayesian Network (BN), which can be utilized to present the corresponding prevention measures. In the second part, the proposed prevention measures are ranked in a cost-effectiveness manner through Best-Fit method and Evidential Reasoning (ER) approach. A case study of vessel collision is analyzed as an illustration. The case study shows that the proposed model can be used to seek out accident causes and rank the derived safety measures from a cost-effectiveness perspective. The proposed model can provide accident investigators with a tool to generate cost-efficient safety intervention strategies.     

Dynamic accident modeling for high-sulfur natural gas gathering station

Dynamic accident modeling for a gas gathering station is implemented to prevent high-sulfur natural gas leakage and develop equipment inspection strategy. The progress of abnormal event occurring in the gas gathering station is modeled by the combination of fault tree and event sequence diagram, based on accident causal chain theory, i.e. the progress is depicted as sequential failure of safety barriers, then, the occurrence probability of the consequence of abnormal event is predicted. Consequences of abnormal events are divided into accidents and accident precursors which include incidents, near misses and so on. The Bayesian theory updates failure probability of safety barrier when a new observation (i.e. accident precursors or accidents data) arrives. Bayesian network then correspondingly updates failure probabilities of basic events of the safety barriers with the ability of abductive reasoning. Consequence occurrence probability is also updated. The results show that occurrence probability trend of different consequences and failure probability trend of safety barriers and basic events of the safety barriers can be obtained using this method. In addition, the critical basic events which play an important role in accidents occurrence are also identified. All of these provide useful information for the maintenance and inspection of the gas gathering station.     

An urban pipeline accident model based on system engineering and game theory

Urban pipeline accidents are caused by complex social-technical factors, in which urban communities and pipeline systems are involved. Such accidents can thus be investigated from the viewpoint of system engineering. System-Theoretic Accident Model and Processes (STAMP) is a systemic method for safety assessment, which has been adopted in many domains. This approach can provide deep insights of accident causes by considering direct and indirect factors. Meanwhile, competition and cooperation between stakeholders in accidents are observed. Therefore, these parties can also be analyzed with the game theory. That is, stakeholders in STAMP can be regarded as players in game. The aim of this paper is to provide a new insight to analyze urban pipeline accidents by considering both STAMP and game theory. In this paper, we proposed an accident model for urban pipelines, with a case study of China-Qingdao pipeline accident occurred in 2013. We concluded that accident reasons can be investigated in-depth and lessons can be learned from analyzing causal factors by using STAMP. Based on results generated from STAMP, we applied the game theory to analyze roles that government and companies act in the China-Qingdao urban pipeline accident. The results show that current punishment and incentive systems are incomplete, lacking of the driving force and constraining force for the stakeholders involved in the accident.     

A conceptual offshore oil and gas process accident model

The purpose of this paper is to present and discuss an accident prevention model for offshore oil and gas processing environments. The accidents that are considered in this work relate specifically to hydrocarbon release scenarios and any escalating events that follow. Using reported industry data, the elements to prevent an accident scenario are identified and placed within a conceptual model to depict the accident progression. The proposed accident model elements are represented as safety barriers designed to prevent the accident scenario from developing. The accident model is intended to be a tool for highlighting vulnerabilities of oil and gas processing operations and to provide guidance on how to minimize their hazards. These vulnerabilities are discussed by applying the 1988 Piper Alpha and the 2005 BP Texas City disaster scenarios to the model.     

基于事故演化网络的旅游安全及风险防控研究

为做好旅游活动的安全管理和风险防控,构建旅游安全事故演化网络,从旅游事故演化的角度分析旅游中常见的事故类型及其演化过程;根据旅游事故发生的时序和相关程度将旅游安全事故分为4级,从事故节点的出入度、子网节点数和支链数进行分析,判断不同旅游事故的风险大小;此外,从不同结构演化链的角度,总结旅游事故演化的特征.结果表明:旅游...     

基于FDA模型的地铁列车洪淹事故致因分析*

为了从安全信息视角探究地铁列车洪淹事故原因,基于FDA（Forecast-Decision-Action）事故致因模型和真实事故案例,构建由个体（地铁行车人员）、自组织（地铁运营企业）和他组织（应急主管部门）3个事故致因子模型组成的地铁列车洪淹事故FDA致因模型,并针对安全管理重要环节提出事故预防建议。研究结果表明:阻断事故致因主链或子链、保证必要安全信息充分且完备、防范安全欺骗行为,可有效预防地铁列车洪淹事故,通过实证案例分析验证FDA模型可显著提升地铁防洪应急管理水平。     

安全信息认知通用模型构建及其启示

为了揭示复杂系统内安全信息传播的机理与故障模式和发展新的安全模型,以安全信息认知过程为主线,以安全信息失真或不对称为问题,构建了1个包含7个关键事件、6个时间状态、5级信息失真和4级信息传播的安全信息认知通用理论模型,阐述了模型的内涵、特点、用途分类和故障诊断分析途径,并由模型推导出1组安全科学基础理论新概念,同时也建立了1种新的安全信息系统分析与控制的方法论。结果表明,该模型对事故致因机理分析、行为安全管理、系统安全设计和事故防控等的具有重要的理论和实际意义。