EUROCONTROL—Systemic Occurrence Analysis Methodology (SOAM)—A 'Reason'-based organisational methodology for analysing incidents and accidents

摘要

The Safety Occurrence Analysis Methodology (SOAM) developed for EUROCONTROL is an accident investigation methodology based on the Reason Model of organisational accidents. The purpose of a SOAM is to broaden the focus of an investigation from human involvement issues, also known as "active failures of operational personnel" under Reason's original model, to include analysis of the latent conditions deeper within the organisation that set the context for the event. Such an approach is consistent with the tenets of Just Culture in which people are encouraged to provide full and open information about how incidents occurred, and are not penalised for errors.A truly systemic approach is not simply a means of transferring responsibility for a safety occurrence from front-line employees to senior managers. A consistent philosophy must be applied, where the investigation process seeks to correct deficiencies wherever they may be found, without attempting to apportion blame or liability.