A New Accident Causation Theory Based on Systems Thinking and its Systemic Accident Analysis Method of Work Systems

The purpose of this paper is to compare three contemporary accident causation models, namely the Swiss Cheese, HFACS, and Fu (2018) Model-based on two accidents existing in the literature. The accidents reviewed are a mine explosion accident and an electrical plant accident. In this way, the validity of the models can be evaluated and weaknesses and strengths revealed. This study discussed the advantages and possible limitations of these models, and according to this discussion, all these models include human and organizational factors and have been found scientific and systematic. According to the results, Fu (2018) and HFACS are more modern, since they were developed based on Swiss Cheese. The product of this research will be a recommendation for safety investigators and accident inspectors which way to turn when choosing the most applicable accident analysis method

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A New Accident Analysis Method Based on Complex Network and Cascading Failure

Discrete Dynamics in Nature and Society ◽

10.1155/2013/437428 ◽

2013 ◽

Vol 2013 ◽

pp. 1-9 ◽

Cited By ~ 3

Author(s):

Ziyan Luo ◽

Keping Li ◽

Xin Ma ◽

Jin Zhou

Keyword(s):

Complex Network ◽

Network Theory ◽

Cascading Failure ◽

Accident Analysis ◽

Analysis Method ◽

Complex Network Theory ◽

Accident Prediction ◽

Prediction And Prevention ◽

Accident Causation ◽

The Government

A new accident causation model is proposed for accident analysis based on the complex network theory. By employing the cascading failure scheme, a new accident investigation method is performed on the associated new model, by which we can reveal key causation factors and key causation factor chains that lead to the final accident. The efficiency of a network is introduced for evaluating the severity of the damage of the whole network and hence the severity of the accident if it happens. All these can provide the government or associations with recommendations for accident prediction and prevention.

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What do applications of systems thinking accident analysis methods tell us about accident causation? A systematic review of applications between 1990 and 2018

Safety Science ◽

10.1016/j.ssci.2019.04.016 ◽

2019 ◽

Vol 117 ◽

pp. 164-183 ◽

Cited By ~ 25

Author(s):

Adam Hulme ◽

Neville A. Stanton ◽

Guy H. Walker ◽

Patrick Waterson ◽

Paul M. Salmon

Keyword(s):

Systematic Review ◽

Systems Thinking ◽

Accident Analysis ◽

Analysis Methods ◽

Accident Causation

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Application of an Improved Model for Accident Analysis: A Case Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph16152756 ◽

2019 ◽

Vol 16 (15) ◽

pp. 2756 ◽

Cited By ~ 3

Author(s):

Jianhao Wang ◽

Mingwei Yan

Keyword(s):

Safety Culture ◽

Safety Climate ◽

Safety Management ◽

Organizational Level ◽

Accident Analysis ◽

Individual Level ◽

Accident Causation ◽

The Individual ◽

Improved Model ◽

Safety Knowledge

An improved accident causation model which demonstrates the relationships among different causal factors was proposed in this study. It provides a pathway for accident analysis from the individual level to the organizational level. Unsafe acts and conditions determined by individuals’ poor safety knowledge, low safety awareness, bad safety habits, etc. are the immediate causes of an accident. Deficiencies in safety management systems and safety culture remain the root causes, which can cause consequences at the individual level. Moreover, the weaknesses of an organization’s safety culture can have a great impact on the formation of a good safety climate and can further lead to poor decision-making and implementation of procedures in the safety management system. In order to contribute to a better perception and understanding of the accident causation model, one typical case in the process industry, the oil leak and explosion of the Sinopec Donghuang pipelines, was selected for this study. The causality from immediate causes to root causes is demonstrated in sequence and can be shown in this model explicitly and logically. Several important lessons are summarized from the results and targeted measures can be taken to avoid similar mistakes in the future. This model provides a clear and resourceful method for the safety and risk practitioner’s toolkit in accident investigation and analysis, and the organization can use it as a tool to conduct staff trainings and thus to keep accidents under control.

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Development and application of ‘systems thinking’ principles for quality improvement

BMJ Open Quality ◽

10.1136/bmjoq-2019-000714 ◽

2020 ◽

Vol 9 (1) ◽

pp. e000714 ◽

Cited By ~ 2

Author(s):

Duncan McNab ◽

John McKay ◽

Steven Shorrock ◽

Sarah Luty ◽

Paul Bowie

Keyword(s):

Systems Thinking ◽

Systems Approach ◽

Healthcare Setting ◽

Work Conditions ◽

Multiple Perspectives ◽

System Safety ◽

Work Systems ◽

Problems And Solutions ◽

Improvement Intervention

Introduction‘Systems thinking’ is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a ‘Safety-II systems approach’ to promote understanding of how safety may be achieved in complex work systems. We aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting.MethodsThe original EUROCONTROL principles were adapted using consensus-building methods with front-line staff and national safety leaders.ResultsSix interrelated principles for healthcare were agreed. The foundation concept acknowledges that ‘most healthcare problems and solutions belong to the system’. Principle 1 outlines the need to seek multiple perspectives to understand system safety. Principle 2 prompts us to consider the influence of prevailing work conditions—demand, capacity, resources and constraints. Principle 3 stresses the importance of analysing interactions and work flow within the system. Principle 4 encourages us to attempt to understand why professional decisions made sense at the time and principle 5 prompts us to explore everyday work including the adjustments made to achieve success in changing system conditions.A case study is used to demonstrate the application in an analysis of a system and in the subsequent improvement intervention design.ConclusionsApplication of the adapted principles underpins, and is characteristic of, a holistic systems approach and may aid care team and organisational system understanding and improvement.

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The Application of Data Mining in the Civil Aviation Accident Analysis

Applied Mechanics and Materials ◽

10.4028/www.scientific.net/amm.241-244.3000 ◽

2012 ◽

Vol 241-244 ◽

pp. 3000-3004

Author(s):

Dai Wu Zhu ◽

Yin Ni

Keyword(s):

Data Mining ◽

Set Theory ◽

Rough Set ◽

Rough Set Theory ◽

Attribute Reduction ◽

Passive State ◽

Civil Aviation ◽

Accident Analysis ◽

Analysis Method ◽

Accident Prediction

At present, our analysis of the aviation accident mainly limited to the methods of mathematical statistics, the analysis method means of a single, and in a passive state, so the accident prediction is poor. This paper, basis on the rough set theory in data mining and preferential information ,we improve the rough set attribute reduction algorithm, and applied to civil aviation accident analysis to indentify the potential law of accident.

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A hybrid accident analysis method to assess potential navigational contingencies: The case of ship grounding

Safety Science ◽

10.1016/j.ssci.2015.06.019 ◽

2015 ◽

Vol 79 ◽

pp. 268-276 ◽

Cited By ~ 40

Author(s):

Emre Akyuz

Keyword(s):

Accident Analysis ◽

Analysis Method ◽

Ship Grounding

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Determining the Optimal Method for Analyzing Specific Accidents (Case study: Falling accidents in the construction project of a combined cycle power plant)

Occupational Hygiene and Health Promotion ◽

10.18502/ohhp.v5i1.6208 ◽

2021 ◽

Author(s):

Reza RADMANFAR ◽

Alireza HAJI HOSSEINI ◽

Reza JAFARI NODOUSHAN

Keyword(s):

Power Plant ◽

Combined Cycle ◽

Accident Analysis ◽

Analysis Method ◽

Decision Matrix ◽

Accident Investigation ◽

Optimal Method ◽

Expert Opinions ◽

Sequence Of Events ◽

Special Power

Introduction: Today, accident investigation and analysis is an important component of safety programs in preventive measures. Incident investigation involves collecting all the information and actual interpretations of an incident, analyzing information to find out the causes of the incident, and writing an incident report. Methods: This descriptive-analytical article was conducted to determine the most important criteria for investigating and selecting the techniques of accident investigation as well as analyzing and selecting the best method of accident analysis in the events of the power plant industry. In this research, previous research studies were studied and expert opinions were collected with regard to the most important criteria for choosing a specific accident analysis method. Later, the 4 accident analysis methods was applied in a special power plant accident and the decision matrix was designed based on the strengths and weaknesses of the model formation. Finally, these four methods were prioritized using the Topsis decision-making method. Results: The key factors in investigating the main criteria for selecting an incident analysis method included the ability to understand the sequence of events in the model, identifying the root causes, descriptiveness and ability to provide reasons for managers and specialists, the need for technical experts, and the time criterion. The TRIPOD BETA method was selected as the best method for analyzing the power accidents. Conclusion: The TRIPOD BETA method was introduced as the most effective method for investigating power plant accidents.

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Extended FRAM by Integrating with Model Checking to Effectively Explore Hazard Evolution

Mathematical Problems in Engineering ◽

10.1155/2015/196107 ◽

2015 ◽

Vol 2015 ◽

pp. 1-11 ◽

Cited By ~ 5

Author(s):

Guihuan Duan ◽

Jin Tian ◽

Juyi Wu

Keyword(s):

Model Checking ◽

System Design ◽

Theory And Practice ◽

Accident Analysis ◽

Analysis Method ◽

Resonance Analysis ◽

Emergent Phenomenon ◽

Counter Example ◽

Model Complex ◽

Safety Constraints

Functional Resonance Analysis Method (FRAM), which defines a systemic framework to model complex systems from the perspective of function and views accidents as emergent phenomenon of function’s variability, is playing an increasingly significant role in the development of systemic accident theory. However, as FRAM is typically taken as a theoretic method, there is a lack of specific approaches or supportive tools to bridge the theory and practice. To fill the gap and contribute to the development of FRAM, (1) function’s variability was described further, with the rules of interaction among variability of different functions being determined and (2) the technology of model checking (MC) was used for the analysis of function’s variability to automatically search the potential paths that could lead to hazards. By means of MC, system’s behaviors (normal or abnormal) are simulated and the counter example(s) that violates the safety constraints and requirements can be provided, if there is any, to improve the system design. The extended FRAM approach was applied to a typical air accident analysis, with more details drawn than the conclusions in the accident report issued officially by Agenzia Nazionale per la Sicurezza del Volo (ANSV).

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