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Accidents and Nonrandom Error Propagation

机译:事故和非随机误差传播

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The use of random elements in accident analyses is practical in that it avoids the need to enumerate all possible failure paths and allows the application of probability analyses to some elements of a complex system. Sometimes, however, the concept of randomness is used only as a residual category to label unexplained features of accident analysis. When common cause failures or system interactions are involved, such an approach can be misleading. Analyses focusing upon nonrandom elements can thus be important in understanding failures of both technical and organizational systems, and some of the problems of such an approach are explored. A detailed analysis of a fatal fire in a railway sleeping car at Taunton, England, in 1978, demonstrates how initial errors can interact with an existing sociotechnical structure to produce new orderly patterns as an accident develops. A simple model to understand this nonrandom error propagation requires a description of the initial system structure in social and technical terms, specifying features such as the task and the sentient boundaries of subsystems. When an error or a set of errors is introduced into this system, the consequent system interventions are structured by the constraints of the preexisting system which they do not destroy. Rather than offering randomness as an account of such phenomena, the analysis encourages a search for regularities in the apparently unstructured events surrounding large‐scale accidents or system failure
机译:在事故分析中使用随机元素是实用的,因为它避免了枚举所有可能的故障路径的需要,并允许将概率分析应用于复杂系统的某些元素。然而,有时随机性的概念仅用作残余类别,用于标记事故分析中无法解释的特征。当涉及常见原因故障或系统交互时,这种方法可能会产生误导。因此,以非随机元素为重点的分析对于理解技术和组织系统的失败非常重要,并探讨了这种方法的一些问题。对1978年英国汤顿铁路卧铺车厢致命火灾的详细分析表明,随着事故的发展,初始错误如何与现有的社会技术结构相互作用,从而产生新的有序模式。理解这种非随机误差传播的简单模型需要用社会和技术术语描述初始系统结构,指定诸如任务和子系统感知边界等特征。当一个错误或一组错误被引入该系统时,随之而来的系统干预是由预先存在的系统的约束构建的,它们不会破坏这些约束。该分析没有提供随机性来解释这些现象,而是鼓励在围绕大规模事故或系统故障的明显非结构化事件中寻找规律性

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