Developing a method to improve safety management systems based on accident investigations: The SAfety FRactal ANalysis

摘要

The concept of a safety management system (SMS) to control the risks of operational activities has been introduced in high-risk industries already some decades ago. SMS requires accidents/incidents to be reported and analysed and measures to be taken to prevent future events. Additionally, national investigating bodies have been given the role of independently investigating serious events, with the same goal. The current practice in accident and incident investigation however, does not provide a systematic approach to analyse elements of SMS. As a direct consequence, the opportunity to use these investigations for introducing sustainable system changes is often missed.