How To Learn From Accidents: Systems thinking' enables holistic reviews

摘要

An often-claimed "fact" is that 70 to 90% of accidents are caused by operators or maintenance workers. Certainly it is true that 70 to 90% are blamed on operators. But are we limiting what we learn from accident investigations by limiting the scope of the inquiry? By applying systems thinking to process safety, we may enhance what we comprehend from accidents and incidents and, in the long run, prevent more of them.