2018年10月24日 星期三

普悠瑪鐵路事故，瑞士奶酪理論？司機員一路求援43分鐘,；明知有異常、失去動力，還一直前進

聽一聽：司機與檢查員的對話
明知有異常、失去動力，還一直前進
天啊，他是有什麼問題嗎


UDN.COM

獨／普悠瑪通聯紀錄完整曝光 司機員一路求援43分鐘 | 普悠瑪出軌究因 | 社會 | 聯合新聞網

瑞士奶酪理論，又稱瑞士起司理論（Swiss Cheese Model）是英國曼徹斯特大學教授James Reason於1990年提出來的。主要是講，瑞士起司在製造與發酵過程當中，很自然的會產生小孔洞。如果把許多片起司重疊在一起，正常情況下，每片起司的空洞位置不同，光線透不過。只有在很極端的情況下，空洞剛好連成一直線，才會讓光線透過去。
Image result for swiss cheese model
The Swiss cheese model of accident causation is amodel used in risk analysis and risk management, including aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth. It likens human systems to multiple slices of swiss cheese, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are "layered" behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize, since other defenses also exist, to prevent a single point of failure. The model was originally formally propounded by Dante Orlandella and James T. Reason of the University of Manchester,[1]and has since gained widespread acceptance. It is sometimes called the cumulative act effect.
Although the Swiss cheese model is respected and considered to be a useful method of relating concepts, it has been subject to criticism that it is used too broadly, and without enough other models or support.[2]

「在災難管理或是病人安全的落實上，有名的瑞士乳酪理論（Swiss Cheese Model）告訴我們：一件錯誤的形成，來自於層層防護的失控。災難並不是單一原因所造成的，而要防範災難的發生，也絕非以過於化約的方式予以懲罰而已。普悠瑪鐵路事故令人難過，然而，我們的社會若是持續瀰漫著想要趕在第一時間抓到元兇的社會氛圍，或是球員兼裁判的組織文化，以及媒體辦案的風氣，其實都無益於未來大眾的安全與利益。」
事件發展迄今，我儘可能不發聲，不獵巫、不捉替死鬼，但也不政治正確發言，立即指向結構、體制什麼的。待事情更明朗化後作檢討才顯周延。時間也許是熱度過後，但那才是必要。

張貼者： 於

沒有留言:

張貼留言

訂閱： 張貼留言 (Atom)