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ID:40718439
大小:34.18 KB
页数:5页
时间:2019-08-06
《How Complex Systems Fail》由会员上传分享,免费在线阅读,更多相关内容在学术论文-天天文库。
1、HowSystemsFailHowComplexSystemsFail(BeingaShortTreatiseontheNatureofFailure;HowFailureisEvaluated;HowFailureisAttributedtoProximateCause;andtheResultingNewUnderstandingofPatientSafety)RichardI.Cook,MDCognitivetechnologiesLaboratoryUniversityofChicago1)Complexsystem
2、sareintrinsicallyhazardoussystems.Alloftheinterestingsystems(e.g.transportation,healthcare,powergeneration)areinherentlyandunavoidablyhazardousbytheownnature.Thefrequencyofhazardexposurecansometimesbechangedbuttheprocessesinvolvedinthesystemarethemselvesintrinsical
3、lyandirreduciblyhazardous.Itisthepresenceofthesehazardsthatdrivesthecreationofdefensesagainsthazardthatcharacterizethesesystems.2)Complexsystemsareheavilyandsuccessfullydefendedagainstfailure.Thehighconsequencesoffailureleadovertimetotheconstructionofmultiplelayers
4、ofdefenseagainstfailure.Thesedefensesincludeobvioustechnicalcomponents(e.g.backupsystems,‘safety’featuresofequipment)andhumancomponents(e.g.training,knowledge)butalsoavarietyoforganizational,institutional,andregulatorydefenses(e.g.policiesandprocedures,certificatio
5、n,workrules,teamtraining).Theeffectofthesemeasuresistoprovideaseriesofshieldsthatnormallydivertoperationsawayfromaccidents.3)Catastropherequiresmultiplefailures–singlepointfailuresarenotenough..Thearrayofdefensesworks.Systemoperationsaregenerallysuccessful.Overtcat
6、astrophicfailureoccurswhensmall,apparentlyinnocuousfailuresjointocreateopportunityforasystemicaccident.Eachofthesesmallfailuresisnecessarytocausecatastrophebutonlythecombinationissufficienttopermitfailure.Putanotherway,therearemanymorefailureopportunitiesthanoverts
7、ystemaccidents.Mostinitialfailuretrajectoriesareblockedbydesignedsystemsafetycomponents.Trajectoriesthatreachtheoperationallevelaremostlyblocked,usuallybypractitioners.4)Complexsystemscontainchangingmixturesoffailureslatentwithinthem.Thecomplexityofthesesystemsmake
8、sitimpossibleforthemtorunwithoutmultipleflawsbeingpresent.Becausetheseareindividuallyinsufficienttocausefailuretheyareregardedasminorfactorsdurin
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