Modeling patterns of breakdown (or archetypes) of human and organizational processes in accidents using system dynamics

Systems approaches to safety have received growing attention in modern accident investigation techniques (e.g., STAMP, Accimap) with the emphasis shifted to the organizational dynamics (or archetypes) that may lead to an erosion of defenses and a drift out of the safety margins. Although the literature contains many applications of archetypes and system dynamics to safety, this richness comes at a cost of learning. It has become very difficult for safety practitioners to integrate the diverse studies of system dynamics with their diverging models. To provide a practical tool of system dynamics in accident investigation, this article reviews earlier studies and integrates them as a classification of patterns of breakdown (or archetypes) of both human and organizational processes on the basis of two control models, that is, the Extended Control Model (ECOM) and the Viable System Model (VSM). In this article, archetypes are represented as variants of two generic templates of performance which exploit many elements of complexity theory and system control. Apart from providing a practical tool to safety practitioners to access the literature on archetypes, the generic templates of ECOM and VSM can be used in building simulators of individual and organizational processes for risk analysis.     

A modified accident analysis and investigation model for the general aviation industry: Emphasizing on human and organizational factors

IntroductionCurrently, there is a lack of specific analytical tools for general aviation accidents (GAAs). This has led to loopholes in the prevention of GAAs.MethodsA Swiss Cheese model for general aviation (SCM-GA) is proposed to identify the human and organizational factors involved in GAAs. In the proposed SCM-GA, 5 categories, 45 subcategories, a general aviation safety management system (GA-SMS) and safety culture were developed based on the classic accident causation models combined with the laws and regulations and safety management practices in the general aviation industry.ResultsOne GAA was analyzed using SCM-GA. The human and organizational causes revealed by SCM-GA were more complete than the causes revealed through the accident report. The identification results of the deficiencies in the subcategories of GA-SMS and the safety culture were more consistent with the requirements in the general aviation laws and regulations than the organizational factors in the accident report. Based on the subcategories of SCM-GA, 41 GAAs that occurred between 1996 and 2010 in China were statistically analyzed and χ² test analyses were performed to estimate the statistical strength of the association between two adjacent subcategories of SCM-GA. The results showed that two adjacent subcategories of SCM-GA were significantly associated. They helped to determine the hidden problems in the accident report based on the path of accident.ConclusionsSCM-GA is an accident analysis tool that can comprehensively analyze the human and organizational deficiencies involved in GAAs. The accident causes revealed by SCM-GA were more consistent with the general aviation safety management practices.Practical applicationsGeneral aviation companies should establish their own GA-SMS and safety culture based on the subcategories developed herein. Using SCM-GA for routine safety inspection and accident investigation will help the management and the staff make effective safety decisions to effectively prevent GAAs.     

The role of safety research in road safety management

Mobility is a matter of great importance in daily life: However, it also causes costs and involves accident risks. To make mobility safer and reduce accident risks, a scientifically based road safety management is needed. Within such a safety management system, a concert of adequate and efficient strategies, tools and measures is developed and implemented. To ensure that the chosen means are efficient they should be derived from research evidence. Secondly, research is also needed to regularly monitor the impact of road safety management tools, serving as a “controlling instrument” for the appropriateness of safety management efforts. This article explains the main strategic aspects of safety management in Germany and illustrates it exemplarily on the basis of two recently implemented road safety measures.     

基于交通量的平面信号控制交叉口交通冲突模拟研究

针对我国交通冲突技术发展尚处于起步阶段 ,交通冲突数据统计尚不充分的现状 ,笔者研究了交通量和交通事故、交通冲突的密切关系 ,尝试建立以交通量为基础的交通冲突数学模型 ,力求更加准确地对平面交叉口进行安全评价 ,克服传统的基于事故统计的安全评价方法的不足。     

基于模糊贴近度的组织安全文化评估方法

鉴于组织安全文化评估过程中,各因素指标及其相互作用关系具有模糊性,引入模糊数学理论,提出一种基于模糊贴近度的组织安全文化评估(SCA)方法。首先,构建组织安全文化因素指标体系以及确定SCA特征状态模式;其次,依据模糊语言隶属度函数以及特征状态模式,确定指标与SCA等级的隶属度;第三,确定指标与各等级的非对称贴近度,依据模糊贴近度判断矩阵进行评估决策;最后,以核电组织安全文化为例,通过对比分析进行方法的验证。实例分析结果的一致性表明:该方法能有效量化系统状态与各评估等级之间的贴近程度,能解决安全文化以及评估状态的模糊性问题,且评估结果与实际状态相吻合。     

组织安全文化评价的基础性问题及方法论

为促进组织安全文化评价研究与实践,针对目前组织安全文化评价研究所存在的根本缺陷,运用文献分析法,对组织安全文化评价的基础性问题及方法论开展系统研究。基于评价的定义,提出组织安全文化评价的定义,并分析其内涵。基于此,提炼与剖析组织安全文化评价的8个基本问题,即评价原则、评价基准、评价对象、评价目的、评价层面、评价范围、评价依据与限制因素,并建构和解析组织安全文化评价的一般程式。结果表明:组织安全文化评价需以明晰上述8个组织安全文化评价的基本问题为前提和基础,需以文献学方法、系统论方法、社会学与心理学方法、数学与统计学方法及具体评价方法5大类方法为指导。     

不良安全文化的特征:事故报告再分析

通过对高风险组织安全管理及事故的研究,对事故报告进行文化意义上的编码分析,揭示导致事故发生的不良安全文化特征。该报告再分析的材料是厂内档案可查的事故报告61份,根据其中55份事故报告的专家编码分析结果,得到了不良安全文化的特征是较低水平的管理对安全的承诺、较差的安全遵守、缺乏应急管理的有效措施、沟通与协调障碍。通过聚类分析,安全文化的各因素可以进一步归为两大类安全促进因素与安全保健因素。从文化的角度来看,分别对应着对组织的承诺和对人的承诺两个维度。     

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.     

Lessons learnt from a crisis event: How to foster a sound safety culture

Recent events in the nuclear industry have blamed a declining safety culture both on the utility and regulatory side as the major responsible. Confidence in the nuclear industry can be dramatically affected by such events. In this context, the present paper analyses a recent crisis event that involved a research reactor. It shows the time history of the event and how its escalation brought to a temporary shut down of the reactor. In-depth analysis of the event pointed out safety culture deficiencies within the organization. The paper presents the key elements in the ensuing organizational change process and describes the different phases (short and long term approaches), players and measures involved in the process that the organisation set up to address deficiencies and improve safety culture. The case represents an interesting example from which important lessons can be learnt. In particular, staff motivation in terms of involvement in improvement activities is considered central in managing safety.     

行为科学关于安全控制的研究述评与未来研究展望

从行为科学的视角,探讨人的因素在事故发生过程中的作用,取得了许多重要的进展。笔者从个体因素、群体因素、组织因素以及跨水平的多因素交互作用等4个方面总结了行为科学关于安全控制的相关研究,分析了各种因素对安全绩效的影响。在此基础上,提出一个包含个体、群体和组织因素在内的整合性事故发生路径模型,指出行为科学关于安全控制的未来研究方向,尤其是需要深入揭示一些高阶变量,如领导、组织学习等对安全生产的影响机制,以及采用跨层次的方法来探讨组织因素、群体因素和个体因素在安全生产过程中的交互作用。     

企业安全生产主体责任绩效评估建模与应用

在全面分析企业安全生产主体责任内涵的基础上,采用问卷调查、访谈等多种手段,从企业依法生产经营、组织机构与人员配置、安全教育培训、员工权益维护、规章制度管理、作业场所管理及事故管理等方面建立系统的企业安全生产主体责任绩效评估指标体系;结合层次分析法和变权综合理论,构建企业安全生产主体责任绩效评估模型,并进行实例应用。结果表明:依法生产经营是对进行安全生产主体责任绩效评估的前提,机构与人员设置、作业场所安全、规章制度、安全教育培训、事故管理、员工权益维护等子体系对落实企业安全生产主体责任的重要性程度依次递减,所构建的企业安全生产主体责任绩效评估方法和模型是有效的。     

数据挖掘在预测组织事故防控效果中的应用*

为进一步探索数据挖据技术在组织事故预防工作中的融入性与适用性,基于24Model构建事故预控基础模型,通过预测准确率数值及接受者操作特性曲线（ROC曲线）对比分析随机森林（RF）、支持向量机(SVM)、决策树（DT）与神经网络（NN）4种方法对组织事故防控效果的预测性能。结果表明:针对事故率控制（Y1）、职业危害预防（Y2）、财产损失3类预测目标（Y3）,RF方法均能达到较高的准确率及稳定性,具有较优的预测性能。根据特征重要度（FI）排序,明确对组织事故水平影响最显著的因素为安全实践活动认知（SC5）及安全管理程序文件（SMS3）,FI值均大于0.150 0。研究结果可为有效预测组织事故防控效果提供方法依据,同时为企业安全工作的规划设计提供思路。     

Understanding and assessing safety culture through the lens of organizational management of uncertainty

The management of uncertainties is discussed as a key challenge for organizations and two approaches to handling uncertainties are introduced, i.e. minimizing uncertainties versus coping with uncertainties. The analysis of rules as for instance laid out in standard operating procedures is suggested as one method for identifying the approach to uncertainty management chosen in a particular organization. Given advantages and disadvantages of both approaches to uncertainty management, loose coupling is discussed as a way of balancing the two approaches and a conceptualization of safety culture as a means for loose coupling is proposed. One of the central controversies underlying discussions on designing organizations for safety, i.e. the relationship between autonomy and safety, is expanded upon in order to deepend the understanding of different design strategies within the framework of uncertainty management. Finally, it is argued that the role and importance of safety culture differs depending on the chosen approach to uncertainty management, requiring that any safety culture assessment is preceeded by an assessment of the fit between the uncertainties an organization is confronted with and the chosen forms of handling these uncertainties. Methods for carrying out these assessments are suggested.     

Measurement of traffic conflicts

Traditionally road accident statistics are used to assess the level of road safety and evaluate road safety programs. In some cases, the lack of good and reliable accident records have hampered proper analyses. A promising approach that overcomes this problem is the traffic conflict technique which relies on observations of critical traffic situations for safety analysis. However, despite the extent of work undertaken in traffic conflict research, there are still a number of issues on conflict measurement and application that have not been well understood by many safety analysts. This has resulted in a general lack of support for the wider application of the technique in safety analysis. This paper shows that one way of using the traffic conflict technique effectively is to ensure that conflicts are quantitatively defined, objectively measured and suitably applied. Before establishing the proposed framework for conflict analysis, the paper first discusses the problems and weaknesses often associated with conflict studies. Considerations for a conflict study based on the proposed approach are then presented and the case of an expressway merging is used to illustrate the method adopted.     

Can focus on safety culture become an excuse for not rethinking design of technology?

Two generic organisational contexts associated with technological designs in relation to safety culture are discussed: (1) operating organisations using existing technologies, and (2) design organisations as producers of technologies. It is argued that the concept of safety culture, if misused, may lead to the adoption of non-effective change strategies in the operational context. On the other hand, it is also argued that design organisations should invest more attention to issues commonly subsumed under the concept of safety culture. In this case, however, the concept of safety culture has to be adapted to fit the demands facing design organisations. Issues of morality and their association with the safety culture concept will be discussed. It is suggested that a stronger focus on understanding innovation and safety together should nourish future research about culture’s influence on design and safety.     

Assessing the maintenance unit of a nuclear power plant – identifying the cultural conceptions concerning the maintenance work and the maintenance organization

Various organizational accidents have indicated that the shared interpretations and experiences of the personnel concerning the work, the organization, and the associated risks are of crucial importance for the safety and effectiveness of the operations. These conceptions are an element of the organizational culture. The cultural conceptions should thus be studied and their contribution to the organizational safety and effectiveness should be assessed proactively. Nevertheless, organizational assessments often focus on either the general safety attitudes and/or values of the personnel, or formal organizational structures and the official practices. In this article a case study is reported that was carried out in a Nordic nuclear power plant maintenance unit. We will illustrate how the employees in the organization construct their work, their organization and the demands of the maintenance task. We focus on explicating and assessing the cultural conceptions prevalent in the maintenance organization. Our aim is to illustrate how the cultural conceptions and organizational practices, tools and the organizing of the work and the organizational climate influence each other, and how they relate to the demands of the maintenance work. The principal methods utilized in the case study were organizational culture questionnaire (CULTURE), semi-structured interviews, group working, and personnel development seminars.     

事故致因“2-4”模型的内涵解析及第6版的研究

为使事故致因“2-4”模型(24Model)在追溯事故原因和制定事故预防对策时取得更好的应用效果,有必要对24Model的内涵进行科学解析。通过文献分析和对比研究,阐述24Model的逻辑结构、原因模块的科学内涵、主要特点。研究结果表明:24Model的主要理论基础,一是HEINRICH、BIRD等提出与改进的多米诺骨牌系列模型,二是REASON提出、SHAPPELL等具体化的瑞士奶酪系列模型和人因分类系统,三是STEWART提出的卓越安全管理模型;静态24Model的逻辑结构以因果关系建立,它属于因果顺序类事故致因模型;静态24Model中事故的直接、间接、根源、根本原因的含义可以从上述3大类事故致因模型、管理体系标准和安全文化的定义中找到根据;动态24Model靠行为演化关系建立逻辑结构,其充分表达自身的系统性、动态性、非线性,并且依靠组织行为即影响行为、个体行为即操作行为,构成一个行为演化系统。     

核电厂人因事故预防的定量化决策

人因事故的分析与预防是核电厂安全运行和管理的重要内容。笔者提出的系统安全性层次分析法主要从两种角度考虑系统的安全性:专家能力权值和安全性矩阵的建立。采用专家判断矩阵确定事故原因对系统安全性的重要度排序。举例某核电厂事故定量分析进行说明,在对事故进行原因分析基础上,构建事故影响因素层次模型,利用层次分析法分析得出事故原因重要度排序由高到低依次为组织管理、操作人员、人机界面、培训与设备状态,并据此提出了相应的预防与改进措施,为安全性要求较高的复杂工业系统提供事故预防的定量化决策依据。     

石化企业安全文化建设

随着国企改制的不断深化,安全管理显现出许多薄弱环节,尤其是在能源勘探开发过程中发生的重特大事故,不断给安全生产发出了黄牌警告.近年来,多种因素导致员工"三违",造成恶性事故不断,其原因是由于企业缺乏安全文化氛围和员工缺乏必要的自我安全保护意识,盲目蛮干导致事故高发.因此,加强企业安全文化建设是提高全员安全意识的一种行之有效的方法,并可以进一步促进和提高员工的自我安全保护意识和安全技术素质.本文阐述了企业安全文化建设在新形势下的重要意义,并针对石化企业开展安全文化建设提出几点建议.     

基于TCT的平面交叉口安全评价方法研究

事故率法是评价平面交叉口交通安全水平常用的方法之一,但因其存在基于事故统计方法固有的因事故的稀有性而使评价周期过长、因事故统计的不完全性致使评价结论欠真、缺乏事故严重性程度的考虑等缺点。笔者针对事故率法评价交叉口安全水平存在的上述问题,在概要介绍交通冲突技术并对交通冲突技术的有效性进行分析的基础上,提出了使事故率法与交通冲突技术相结合,用交通冲突代替交通事故改善交叉口事故率法的理论设想。进而,结合质量控制法,研究了同类型交叉口的交通冲突率的临界值的确定,提出了基于交通冲突技术和交叉口交通冲突率的评价方法。