Systems thinking, the Swiss Cheese Model and accident analysis: A comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models

事故(哲学) 因果关系 系统思维 事故分析 脱轨 工程类 风险分析(工程) 运筹学 计算机科学 运输工程 业务 人工智能 磁道(磁盘驱动器) 认识论 政治学 哲学 机械工程 法学
作者
Peter G. Underwood,Patrick Waterson
出处
期刊:Accident Analysis & Prevention [Elsevier]
卷期号:68: 75-94 被引量:264
标识
DOI:10.1016/j.aap.2013.07.027
摘要

The Swiss Cheese Model (SCM) is the most popular accident causation model and is widely used throughout various industries. A debate exists in the research literature over whether the SCM remains a viable tool for accident analysis. Critics of the model suggest that it provides a sequential, oversimplified view of accidents. Conversely, proponents suggest that it embodies the concepts of systems theory, as per the contemporary systemic analysis techniques. The aim of this paper was to consider whether the SCM can provide a systems thinking approach and remain a viable option for accident analysis. To achieve this, the train derailment at Grayrigg was analysed with an SCM-based model (the ATSB accident investigation model) and two systemic accident analysis methods (AcciMap and STAMP). The analysis outputs and usage of the techniques were compared. The findings of the study showed that each model applied the systems thinking approach. However, the ATSB model and AcciMap graphically presented their findings in a more succinct manner, whereas STAMP more clearly embodied the concepts of systems theory. The study suggests that, whilst the selection of an analysis method is subject to trade-offs that practitioners and researchers must make, the SCM remains a viable model for accident analysis.
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