Learning from incidents: from normal accidents to high reliability 论文

详细信息

发表期刊/会议

System Dynamics Review

发表日期

2006-01-01

发表年份

2006

摘要

Many disasters have occurred because organizations have ignored the warning signs of precursor incidents or have failed to learn from the lessons of the past. Normal accident theory suggests that disasters are the unwanted, but inevitable output of complex socio-technical systems, while high-reliability theory sees disasters as preventable by certain characteristics or response systems of the organization. We develop an organizational response system called incident learning in which normal precursor incidents are used in a learning process to combat complacency and avoid disasters. We build a model of a safety and incident learning system and explore its dynamics. We use the model to motivate managers to implement incident learning systems as a way of moving safety performance from normal accidents to high reliability. The simulation model behavior provides useful insights for managers concerned with the design and operation of incident learning systems. Copyright © 2006 John Wiley & Sons, Ltd.