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 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.     

The affective foundations of high‐reliability organizing

The factors that compel individuals to exert the extraordinary effort needed to create high reliability—consistent error‐free performance under trying conditions—remain unspecified. Here, we propose that when individuals experience emotional ambivalence and prosocial motivation, it induces the broad thinking and other‐orientation that undergird mindful organizing and high reliability. Copyright © 2014 John Wiley & Sons, Ltd.     

The challenge of collective learning from event analysis

This paper examines the difficulties of learning from event analysis. The central idea is that learning represents a distinct set of team-or unit-level outcomes and processes that is different from valid analysis, effective problem-solving, or individual learning. In other words, event analysis cannot automatically generate group learning. For learning to occur, several conditions must be satisfied: Change in the team’s or unit’s repertoire of behaviors (the learning) must be a clear outcome of the event analysis; this learning must be shared by the team members (i.e., members must become aware of both the content of the learning as well as of the fact that other members are aware of this learning); the shared learning must be stored in repositories for future retrieval; the stored learning must be retrieved when the team subsequently encounters situations where the learning is relevant; and, finally, these processes of sharing, storing, and retrieving the learning must continue to occur over an extended period of time. These requirements pose major dilemmas or challenges for learning from event analysis. We discuss these challenges using examples from event analysis teams in two hospitals and in a computer emergency response center. We offer some potential strategies for addressing these challenges.     

安全技术中图像质量的主客观评估

目前,图像的传递和存储应用了许多不同的图像压缩技术.这些压缩技术对图像的感知及其最终判读有重要影响.这些影响在诸如数字电视等相对宽带的系统中还不是太重要,但在窄带系统中就变得极其重要了.     

A framework for learning from incidents in the workplace

Learning from Incidents (LFI) in the workplace has been gaining increasing importance in the Health, Safety and Environment context. Although organisations adopt a variety of LFI initiatives, it is often unclear what learning approaches are the most appropriate and the most effective for different types of incidents across a range of contexts. The aim of the paper is to surface factors that are important for effective Learning from Incidents (LFI). The paper builds on a conceptual framework for learning from incidents, developed through an earlier study. This conceptual framework was validated through empirical data collected at two multinational corporations in the energy sector. From this data a refined framework for learning from incidents was devised with five factors important for LFI: participants of learning, type of incidents, learning process, type of knowledge and learning context. This framework can be used as an evaluation tool and as a guidance tool to develop holistic, organisational learning approaches.     

Effect of Subjective and Objective Workload on Asthenopia at VDU Workplaces

An ergophthalmological tool has been developed to investigate effects of subjective and objective workload on work-related visual complaints (asthenopia). In field studies on different visual display unit (VDU) workplaces effects of objective and subjective workload, work intensity, and work breaks (5-9 min/hour) could be found. It could be shown that during the first hours of VDU work, asthenopic complaints have the tendency to follow effective workload. With increasing working time the effect of a general and visual fatigue overlaps other reported visual complaints in the majority of cases.     

Safety in fishing — learning from experience

This article critically examines the level of safety in some sections of the UK fishing industry not only by looking at the available statistics but also by examining actual recent case histories.In 1989 the UK Department of Transport established the Marine Accident Investigation Branch (MAIB). Case histories published by MAIB have been taken as the basis for the article in order to illustrate and draw lessons from incidents that occur in fishing.Fishing will always be a high risk profession but there are ways in which risks can be diminished. Many of the problems are due to vessels being built below the 12 m threshold at which the 1975 Safety Rules currently apply. Some of the vessels lack adequate reserve stability to withstand capsize in the dynamic situation and there are deficiences in design and safety equipment. The training programmes introduced by Seafish for Survival, Fire Fighting and First Aid are now mandatory for all new entrants and these have almost certainly resulted in the saving of lives. However, there needs to be a much greater awareness of accident prevention and the article makes a plea for this to be given more attention.Each case study is probably unique or there are some specific circumstances as to why the accident happened. Nevertheless, there are always underlying lessons to be learnt from every incident of this type, even if there is no loss of life or serious injury.     

Resources and coping with stressful events

This longitudinal, quasi‐field experiment tested whether perceived stress and increase in perceived stress are related to the resources of the individual, namely, personality (core self evaluation scale (CSES)), physical fitness, social support (acceptance and/or rejection by peers), and cognitive abilities. Perceived stress scale (PSS) was administered at two points in time to participants in a two‐day selection process for a military unit, whose stressful environment formed the manipulation in this study. Baseline PSS was obtained from soldiers before the selection activity, when threatened with resource loss. PSS was next administered during the selection activity, when individuals had to cope with actual loss of resources and difficulty in regaining them. As expected, participants perceived more stress during the selection activity. Participants with higher CSES, higher cognitive abilities and higher levels of social support perceived lower stress levels prior to the activity. The increase in stress level was lower for participants with better fitness levels, but greater for participants rejected by their peers. Exploratory analysis of resource overlap was conducted and revealed a contribution of few key resources to coping, even in the presence of other resources. Copyright © 2008 John Wiley & Sons, Ltd.     

2007年5-6月国内环境事件

简要统计了2007年5-6月国内发生的各种环境事件123起,包括沙尘天气10起,污染事件23起,地震15起,山体滑坡和泥石流13起,旱灾5起,以及其他自然灾害57起.对自然灾害进行了讨论.     

2008年11-12月国内环境事件

简要统计了2008年11-12月国内发生的各种环境事件69起,包括沙尘天气2起,污染事件18起,地震34起,山体滑坡和泥石流7起,旱灾2起以及其他自然灾害6起.     

2007年11-12月国内环境事件

简要统计了2007年11-12月国内发生的各种环境事件47起,包括沙尘天气2起,污染事件15起,地震22起,山体滑坡和泥石流6起,以及旱灾2起.对自然灾害进行了讨论.     

2006年3-4月国内环境事件

简要统计了2006年3-4月国内发生的各种环境事件125起,包括沙尘天气13起,污染事件64起,地震13起,山体滑坡和泥石流7起,虫害3起,以及其他自然灾害25起.对沙尘和污染进行了讨论.     

2012年7-8月国内环境事件

简要统计了2012年7-8月国内发生的各种环境事件155起,包括沙尘天气2起,污染事件28起,地震50起,山体滑坡和泥石流33起,旱灾3起以及其他自然灾害39起.     

2012年1—2月国内环境事件

简要统计了2012年1—2月国内发生的各种环境事件78起,包括沙尘天气3起,污染事件18起,地震34起,山体滑坡和泥石流7起,旱灾4起以及其他自然灾害12起。     

2009年11-12月国内环境事件

简要统计了2009年11-12月国内发生的各种环境事件68起,包括沙尘天气2起,污染事件14起,地震40起,山体滑坡和泥石流7起,旱灾3起以及其他自然灾害2起.     

2010年7-8月国内环境事件

简要统计了2010年7-8月国内发生的各种环境事件138起,包括沙尘天气4起,污染事件21起,地震40起,山体滑坡和泥石流38起,旱灾3起以及其他自然灾害32起.     

2010年9-10月国内环境事件

简要统计了2010年9-10月国内发生的各种环境事件89起,包括沙尘天气4起,污染事件16起,地震43起,山体滑坡和泥石流11起,旱灾2起以及其他自然灾害13起.     

2006年5-6月国内环境事件

简要统计了2006年5-6月国内发生的各种环境事件197起,包括沙尘天气18起,污染事件48起,地震13起,山体滑坡和泥石流22起,虫害12起,旱灾15起,以及其他自然灾害69起.对自然灾害进行了讨论.