• پیشگفتار

  • هدف علم ایمنی جلوگیری از حوادث است. با این حال، بهبود ایمنی سیستم‌ها از طریق کاهش حوادث همچنان چالش برای دانشمندان ایمنی است (گرانت و همکاران ، 2018). مدل‌های علیت حادثه، به شفاف‌سازی علت، فرآیند و عواقب حوادث کمک می‌کنند و تحلیلی دقیق از وقوع و توسعه آن‌ها ارائه می‌دهند. با استفاده از مدل علیت حادثه برای تحلیل حادثه، می‌توان به‌راحتی علل مختلف حادثه و نقاط ضعف کاستی‌ها2 در فرآیند تولید را شناسایی کرد (علی و همکاران3، 2014). این امر در اجرای مسئولیت پس از حادثه و پیشگیری از حوادث آینده نقش حیاتی دارد. به‌عنوان مهم‌ترین مبانی نظری و روش تحقیق در علم ایمنی، لازم است تاریخچۀ توسعۀ مدل‌های علیتی حادثه به‌طور واضح و روشن تفسیر و شرح داده شود.

  • در دوران باستان، سطح تحصیلات نسبتاً ابتدایی بود و مردم وقوع حوادث را خواست خدا می‌دانستند.از ابتدای دوران انقلاب صنعتی، تولیدات انسانی دستخوش تغییرات عمده‌ای شده و نرخ مرگ و میر کارگران به میزان چشمگیری افزایش‌یافته است و به جبران خسارت (غرامت) کارگران برای صدمات جسمانی ناشی از کار منجر شده است. برای حل تعارض میان کارفرمایان و کارمندان در مسئلۀ جبران خسارت، به‌تدریج سیستم‌های حقوقی خاصی در مورد جبران خسارت کارگران بوجود آمده است. به‌عنوان‌مثال، در سال ۱۹۰۸ ایالت نیویورک قانون جبران خسارت کارگران را تصویب کرد (اپشتین4 ،1981). پس از آن، ایالات‌متحده "جنبش ایمنی" معروف را راه‌اندازی کرد و مردم شروع به مطالعه علل حوادث و چگونگی پیشگیری از آنها کردند (فو5، 2013). در سال 1919‌، گرین‌وود و وودز6 (1919) گرایش مستعد حادثه را پیشنهاد کردند، که اولین مدل علیت حادثه در تاریخ بشر شد. سال 2019 نشان از گذراندن 100 سال مطالعه درباره مدل‌های علیت حادثه است.

  • در قرن گذشته، تجربیات بسیاری دربارۀ صدمات جسمانی و حوادث جمع‌آوری شده، و علل و قوانین پیشگیری از حوادث مورد بررسی قرارگرفته است. بر این اساس، در مورد چرایی و چگونگی وقوع حوادث و روش‌های پیشگیری از آن‌ها، تفکر و تحقیق زیادی انجام‌شده است و دیدگاه‌ها و مدل‌های متعددی پیشنهادشده است. مدل‌های اولیه علیت حوادث عمدتاً مربوط به عوامل انسانی در حوادث است. مدلهای نماینده شامل مدل‌های گرایش مستعد حادثه (گرین وود و وودز، 1919)، مسئولیت حادثه (مینتز و بلوم ، 1949) و مدل سری (سری2، 1969) هستند.

  • پس از آن، تمرکز پیشگیری از حوادث به سمت انرژی، یعنی نحوه جلوگیری از آزادسازی و انتقال انرژی، سوق پیدا کرد.

  • مدل‌های نماینده3 شامل تئوری انتقال انرژی هادون4 (1968)، مدل تری پود بتا5 و مدل پاپیون6 (استمن و همکاران7 ، 2018؛ کلوتیه و همکاران8، 2018؛ کرومیر و همکاران9، 2019) هستند.

  • در سالهای اخیر، تمرکز مدل‌های علیت حوادث بر مدل‌های سازمان یافته10 مانند AcciMap ((راسموسن11 ، 1997; سامو و همکاران12، 2017; گنکالوز و همکاران13، 2019))، CREAM ((هولناگل14،1998 ; آنگ15 ،2019)) ، STAMP ((لوسون16، 2004; استنتون و همکاران17، 2019))، FRAM ((هولناگل، 2012; ابوذر و همکاران18، 2018)) تغییر کرده است. این مدل‌ها به‌خاطر تحلیل عمیق‌تر علل حوادث و وجود روابط منطقی واضح‌تر محبوبیت بیشتری پیدا کرده‌اند. از زمان ارائه نظریه دومینو توسط هاینریش19 (1931)، مدل علیت حادثه خطی به‌دلیل دسته‌بندی واضح علل حادثه به خوبی مورد استقبال قرار گرفته است.

  • پس از آن، مدل پنیر سوئیسی20 (ریزون21، 1990، 1997، 2008؛ هولناگل، 2004) و HFACS (شاپل و ویگمن22، 2001، 2003، 2004) نیز به‌طور گسترده‌ای مورد استقبال قرار گرفتند. اگرچه مدل‌های علیت حادثه در دوره‌های مختلف تفاوت دارند، اما همگی نقش مهمی در کاهش حوادث دارند. در توسعه مدل‌های علیت حادثه، هنوز چالش های زیادی وجود دارد که باید حل شود.

  • 1- مطالعات مروری درمورد توسعه مدل‌های علیت حادثه بسیار اندک است. اگرچه برخی از پژوهشگران مدل‌های علیت حادثه را معرفی کرده‌اند (قریشی23، 2007؛ علی و همکاران، 2014؛ لیت همکاران ، 2017؛ پاسمان و همکاران2، 2018) ، اما این معرفی‌ها سازمان یافته نبوده است. برخی از مدل‌های علیت حادثه کلاسیک به‌دلیل سابقه طولانی خود به‌تدریج ناپدید شده‌اند و این امر به فقدان مطالعات سازمان یافته و جامع در این حوزه منجر شده است. بنابراین، بررسی سازمان یافته مدل‌های علیت حادثه در 100 سال گذشته ضروری است.

  • 2- معرفی‌های کمی دربارۀ شرایط کاربرد مدل‌های علیت حادثه وجود دارد. هر مدل علی حادثه در یک زمینه و با تاریخ خاص خود تنظیم و طراحی شده و مزایا و معایب خاص خود را دارد. استفاده از مدل علیت حادثه مستلزم آشنایی با شرایط کاربردی مدل است. برخی از مدل‌های کلاسیک حادثه، مانند مدل پنیر سوئیسی و HFACS، به‌طور گسترده‌ای شناخته‌شده و مورد استفاده قرارگرفته‌اند. اما برخی مدل‌های قدیمی‌تر مانند مدل برد (برد و جرمین3، 1966، 1996؛ کوجث و همکاران4، 2010)، مدل هال ((هال و هال5 ، 1970)) و مدل لارنس (لارنس6، 1974) به‌خوبی شناخته نشده‌اند. این مدل‌ها ویژگی‌های کاربردی خاص خود را دارند که باید برای استفاده از آنها با آنها آشنا شد.

  • 3- معرفی‌های کافی برای مدل‌های جدید علیت حادثه وجود ندارد. باگذشت زمان، مدل‌های علیت حادثه همچنان در حال توسعه هستند. آخرین مدل‌های علیت حادثه از دیدگاه نظری کامل‌تر هستند و از مزایای آنالیز و پیشگیری از حادثه برخوردار هستند. چندین مدل جدید، به‌ویژه آنهایی که نوآوری‌های نظری دارند، مانند مدل استوارت (استوارت7، 2001)، مدل حادثه شغلی (آتوود و همکاران8، a,b,c2006)، مدل فرآیند نفت و گاز فراساحلی (کوجث و همکاران، 2010)) SHIPP ((راسنیاکا و همکاران9 ، a,b2011))، چارچوب TeCSMART ((ونکاتاسوبرامانیان و ژانگ10، 2016))، مدل 24 ((فو و همکاران11، 2018، 2019)) نیاز به معرفی دارند.

  • 4- در مورد اینکه چگونه مدل‌های علیت حادثه در تقویت پیشگیری از حوادث مؤثرتر هستند، با فقدان تفکر عمیق روبرو هستیم.

  • راثنایاکا از تحلیل کیفی (گنکالوز و همکاران، 2019؛ استنتون و همکاران، 2019) تا تحلیل کمی (آنگ، 2019؛ هان و همکاران ، 2019) و تحلیل های پویا (خاکزاد و همکاران2، a2012 ،b2012 ،2013؛ زارعی و همکاران3، 2017)، مدل های علیت حادثه به تدریج در خدمات خود به علم ایمنی بهبود می‌یابند. در عصر هوش مصنوعی و داده‌های کلان4، استفاده از مدل‌های علیت حادثه برای پیشگیری عمیق‌تر از حوادث نیز یکی از حوزه‌های فعال تحقیقات علمی ایمنی خواهد بود.

  • به‌طور خلاصه، برای جلوگیری از حوادث به‌طور مؤثرتر، لازم است تاریخچه مدل‌های علیت حادثه ایجاد شده در 100 سال گذشته، به‌ویژه مدل‌های خاص کلاسیک و ابتکاری نظری، روشن شود. پیشینه، تاریخچه توسعه‌، جریان کاربرد و وضعیت کاربرد این مدل‌ها به‌طور کامل شرح ‌داده‌شده است. علاوه بر این، روند توسعه و روند کاربرد آنها مورد بحث قرارگرفته است. امید است که این بررسی به توسعه مدل‌های علیت حادثه کمک کرده و به نتایج بهتر در پیش‌بینی و پیشگیری از حوادث کمک کند.

  • هدف و پاداش برگردانندگان و دیگر کسانی که از آغاز تا پایان درگیر بوده‌اند، بیشتر از هرچیز امید به خوشنودی پروردگار متعال و همراه و همگام شدن دیگر عزیزانی است که می‌خواهند گره‌ای از مشکلات این جامعه بگشایند. آنچه شده، آغاز است و آنچه باید بشود کرانه‌ای در دوردست‌ها دارد.

  • تقاضامنديم دانشمندان و علاقه‌مندان، نکات و نظریات ارشادی خویش را در جهت رفع اشکالات اعلام نمایند.

  • محمد امین موعودی

  • Mououdi 2006@ yahoo.com

  • آرزو سماک امانی

  • Arezoo.sam 76@ yahoo.com

  • فهرست

    پیشگفتار الف

    مدل‌های علیت حادثه (Accident Causation Model) 2

    طبقه‌بندی مدل‌های علیت حادثه 3

    مدل‌های خطی 3

    مدل‌ها‌ی خطی پيچيده (complex linear) 4

    مدل‌های علیت حادثه مبتنی بر انسان 5

    مدل علیت حادثه مبتنی بر آمار 13

    مدل هرم حادثه 13

    مدل علیت حادثه مبتنی بر انرژی 16

    مدل تریپودبتا (Tripod beta) 22

    مدل پاپیون 27

    مدل‌ها‌ی علیت حادثه مبتنی بر سیستم 34

    مدل اپیدمیولوژی حادثه 34

    مدل 3M 35

    مدل 5M 35

    مدل سیستم فنی- اجتماعی و نقشه‌برداری حادثه 37

    روش تجزیه و تحلیل خطا با تاکید بر قابلیت اطمینان شناختی انسان (CREAM) 39

    مدل و فرآيندهای حادثه مبتنی بر نظریه سیستم‌ها (STAMP) 47

    رویه یکپارچه برای تجزیه‌وتحلیل علل رویداد(IPICA) 51

    روش واكاوي حادثه مبتني بر تشديد عملكرد (FRAM) 53

    مدل TeCSMART (مدل سیستم هدف محور برای تحلیل ریسک‌ها‌ و تهدیدها) 57

    مدل‌ها‌ی علیت خطی 59

    سیستم آناليز و طبقه‌بندی فاکتورهای انسانی (HFACS) 61

    مدل علیت حادثه بِرد 63

    مدل علیت حادثه کیتاگاوا 64

    نظریه مدار متقاطع (OIT) 65

    تئوري دومينو ‌ها‌ینریش (1931) 67

    مدل پنير سوئيسي (SCM) 71

    مدل عليت حادثه استوارت 75

    مدل حادثه شغلی (OAC) 77

    مدل حادثه فرآیند نفت و گاز فراساحلی (OOGM) 80

    شناسايي، پيش‌بيني و پيشگيري خطر سيستم (SHIPP) 81

    24Model 85

    مقایسه مدلهای حادثه 90

    پیوست‌ (روش‌های کنترل ایمنی رفتاری) 97

    B-Safe 98

    فلسفه B-Safe: 98

    فرایند B-Safe 98

    توقف به منظور حفظ ایمنی (TOFS) 98

    ممیزی ایمنی پیشرفته (ASA) 99

    برنامه آموزش و مشاهدات ایمنی (STOP) 101

    کارت STOP 103

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