复杂社会技术系统事故成因结构敏感性分析

Structural Sensitivity Analysis of Accident Causation in Complex Social-technical System

讨论基于共同成因假设思想的事故成因理论的局限:①不考虑系统复杂性影响,认为复杂系统和简单系统都遵循同样的事故成因机理;②共同成因假设,即大小事故具有相同的成因,遵循共同成因路径;③因果律假设,即任何事故一定有清晰严格的因果链;④只注重比较重要因素,人为增加了系统的不和谐。系统地阐述复杂系统事故所具有的结构敏感性,给出了事故成因模型有效性的价值判断标准,并提出活跃元素的行为偏差及活跃元素间交互作用偏差的合成是决定复杂社会技术系统事故成因机理的学说,补充并完善了Reason的Swisscheese模型,同时构建了基于结构敏感性的事故成因模型。

The limitations of the idea of the common cause hypothesis are systematically discussed as follows ： （ 1 ） neglecting the impact of system complexity, and supposing simple and complex systems follow the same mechanism of accident causation ; （2） common causes hypothesis, that is, minor or serious accidents have the same causes and follow common causes path ; （3） hypothesis of causality, that is, any accident can be traced by a clear strict cause-effect chain; （4） just focusing on the important factors, artificially increasing the system disharmony. Then, the structural sensitivity of the accidents occurring in the complex systems is expounded. The value criteria for judging the effectiveness of the accident causation models is given. Accidents causation theory of complex social-technical systems based on the combination of the behavior deflection of the active elements and deflection of interactions between active elements is put forward. Reason＇s Swiss Cheese model is supplemented and perfected, and new accidents causation model based on the structural sensitivity is formulated.