Antaganden om olycksfall - Konsekvenser för utredning.pdf
Antaganden om olycksfall - Konsekvenser för utredning.pdf
Antaganden om olycksfall - Konsekvenser för utredning.pdf
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Industrial<br />
revolution<br />
21 April 2010<br />
Historiskt sätt har fokus<br />
på olika orsaksk<strong>om</strong>binationer varierat<br />
1769 1860<br />
1910<br />
2010<br />
1930 1956 1960<br />
D<strong>om</strong>ino theory<br />
& Iceberg model<br />
1950<br />
C<strong>om</strong>puterization<br />
Accident<br />
syndr<strong>om</strong>e<br />
Barrierenergy<br />
concept<br />
AGENT<br />
Accident prone individual<br />
(sex, age)<br />
ACCIDENT HOST<br />
Fast car with bad tyres<br />
ENVIRONMENT<br />
Physical environment (e.g. winter)<br />
(Socio-econ<strong>om</strong>y)<br />
Epidemiological<br />
model<br />
1961<br />
1979<br />
Three<br />
mile<br />
island<br />
ACITIVITY<br />
Flying an aircraft<br />
Bulid-up<br />
Discrepand causual chains<br />
(not noticed)<br />
Surprise<br />
DISASTER<br />
Man-made<br />
disasters<br />
1978<br />
Normal<br />
Accidents<br />
1984<br />
(repeated similar actions)<br />
WORK<br />
NORMAL<br />
1986<br />
Chernobyl,<br />
Challenger<br />
Latent conditions:<br />
failed or absent<br />
defenses<br />
Active failures<br />
Organizational influences<br />
Unsafe supervision<br />
Preconditions for unsafe acts<br />
Unsafe acts<br />
Swiss<br />
cheeze<br />
1990
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