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Highlights from the literature on accident causation and system safety:Review of major ideas, recent contributions, and challenges

机译：事故原因和系统安全方面的文献亮点：回顾主要思想，最新贡献和挑战

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This work constitutes a short guide to the extensive but fragmented literature on accident causation and system safety.rnAfter briefly motivating the interest in accident causation and discussing the notion of a safety value chain, we delve into our multi-disciplinary review with discussions of Man Made Disasters, Normal Accident, and the High Reliability Organizations (HRO) paradigm. The HRO literature intersects an extensive literature on safety culture, a subject we then briefly touch upon. Following this discussion, we note that while these social and organizational contributions have significantly enriched our understanding of accident causation and system safety, they have important deficiencies and are lacking in their understanding of technical and design drivers of system safety and accident causation. These missing ingredients, we argue, were provided in part by the development of Probabilistic Risk Assessment (PRA). The idea of anticipating possible accident scenarios, based on the system design and configuration, as well as its technical and operational characteristics, constitutes an important contribution of PRA, which builds on and extends earlier contributions made by the development of Fault Tree and Event Tree Analysis. We follow the discussion of PRA with an exposition of the concept of safety barriers and the principle of defense-in-depth, both of which emphasize the functions and "safety elements [that should be] deliberately inserted" along potential accident trajectories to prevent, contain, or mitigate accidents. Finally, we discuss two ideas that are emerging as foundational in the literature on system safety and accident causation, namely that system safety is a "control problem", and that it requires a "system theoretic" approach to be dealt with. We clarify these characterizations and indicate research opportunities to be pursued along these directions.rnWe conclude this work with two general recommendations: (1) that more fundamental research and cross-talk across several academic disciplines must be supported and incentivized for tackling the multi-disciplinary issues of accident causation and system safety (e.g., through the creation "academic hubs" or "centers of excellence" dedicated to system safety); and (2) that more interactions and partnerships between academia, industry, and government (especially accident investigation agencies) on accident causation and system safety issues would be particularly useful for all involved in advancing the safety agenda, from both research and education perspectives, and for disseminating research results, safety recommendations, and lessons learned from accident investigations.
机译：这项工作构成了关于事故因果关系和系统安全性的广泛但零散的文献的简短指南。rn在简短地激发了对事故因果关系的兴趣并讨论了安全价值链的概念之后，我们通过对人为因素的讨论深入研究了多学科综述灾难，正常事故和高可靠性组织（HRO）范例。 HRO文献与有关安全文化的大量文献相交，然后我们简要介绍了这一主题。在讨论之后，我们注意到，尽管这些社会和组织的贡献大大丰富了我们对事故原因和系统安全性的理解，但它们具有重要的缺陷，并且对系统安全和事故原因的技术和设计驱动力缺乏了解。我们认为，这些缺失的成分部分是由概率风险评估（PRA）的开发提供的。基于系统设计和配置以及其技术和操作特性来预测可能发生的事故场景的想法，构成了PRA的重要贡献，它基于故障树和事件树分析的发展做出的早期贡献并得到了扩展。 。在PRA讨论之后，我们将阐述安全壁垒的概念和纵深防御的原则，它们都强调了功能和“应故意插入的安全要素”沿着潜在事故轨迹的发生，以防止，遏制或减轻事故。最后，我们讨论了在系统安全和事故原因方面作为基础文献涌现的两种思想，即系统安全是一个“控制问题”，并且它需要处理“系统理论”方法。我们阐明了这些特征并指出了沿着这些方向进行研究的机会。我们在完成这项工作时提出了两个一般性建议：（1）必须支持和激励跨多个学科的基础研究和交叉对话，以解决多学科问题事故原因和系统安全问题（例如，通过创建专门用于系统安全的“学术中心”或“卓越中心”）； （2）学术界，产业界和政府（尤其是事故调查机构）之间就事故因果和系统安全问题进行更多的互动和建立伙伴关系，无论是从研究还是从教育的角度来看，对于所有参与推进安全议程的各方都将特别有用，并且用于传播研究结果，安全建议以及从事故调查中学到的经验教训。

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