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TOWARDS A DEEPER LEVEL OF LEARNING FROM INCIDENTS: USE OF SCENARIOS

机译:迈向事故学习的更深层次:场景的使用

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This paper describes a project that arose from a serious maritime incident. In such circumstances there is always a difficulty in ensuring that generic lessons are learned (which could apply to many operations and types of equipment) and not being distracted by the specifics of the incident (the specific type of operation or equipment). For example, van Wijk, Taylor and May (2009) reviewed ten major incidents from many industrial sectors, and identified eight common organisational and cultural failings, which were independent of the specific technology or sector.Once the immediate aftermath of this specific maritime incident had passed, business leaders posed the question "could something like that happen again?". The approach taken was to simulate "something like that" -namely an incident with similar generic characteristics. It is common to simulate incidents for people directly controlling technical systems (e.g. putting pilots or control room operators in high-fidelity simulators), and to develop incident commanders' emergency response competence (e.g. Flin, 1996).
机译:本文描述了一个源自严重海事事件的项目。在这种情况下,始终难以确保学习到一般性的经验教训(这可能适用于许多操作和设备类型),并且不会因事件的具体内容(操作或设备的特定类型)而分心。例如,van Wijk,Taylor和May(2009)回顾了来自许多工业部门的十起重大事件,并确定了八起常见的组织和文化缺陷,这些缺陷与特定的技术或部门无关。通过之后,企业领导者提出了一个问题,“类似的事情还会再次发生吗?”。采取的方法是模拟“类似的东西”,即具有类似通用特征的事件。通常情况下,对直接控制技术系统的人员进行事件模拟(例如将飞行员或控制室操作员置于高保真模拟器中),并发展事件指挥官的应急能力(例如Flin,1996)。

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