Accident precursors, near misses, and warning signs: Critical review and formal definitions within the framework of Discrete Event Systems

摘要

An important consideration in safety analysis and accident prevention is the identification of and response to accident precursors. These off-nominal events are opportunities to recognize potential accident pathogens, identify overlooked accident sequences, and make technical and organizational decisions to address them before further escalation can occur. When handled properly, the identification of precursors provides an opportunity to interrupt an accident sequence from unfolding; when ignored or missed, precursors may only provide tragic proof after the fact that an accident was preventable.In this work, we first provide a critical review of the concept of precursor, and we highlight important features that ought to be distinguished whenever accident precursors are discussed. We address for example the notion of ex-ante and ex-post precursors, identified for postulated and instantiated (occurred) accident sequences respectively, and we discuss the feature of transferability of precursors. We then develop a formal (mathematical) definition of accident precursors as truncated accident sequences within the modeling framework of Discrete Event Systems. Additionally, we examine the related notions of "accident pathogens" as static or lurking adverse conditions that can contribute to or aggravate an accident, as well as "near misses", "warning signs" and the novel concept of "accident pathway". While these terms are within the same linguistic neighborhood as "accident precursors", we argue that there are subtle but important differences between them and recommend that they not be used interchangeably for the sake of accuracy and clarity of communication within the risk and safety community. We also propose venues for developing quantitative importance measures for accident precursors, similar to component importance measures in reliability engineering. Our objective is to establish a common understanding and clear delineation of these terms, and by bringing formal mathematical tools to bear on them, we hope to provide a richer basis and more interpretive possibilities for examining and understanding risk and safety issues.