Citation

Fan Y, Li Z, Pei J, Li H, Sun J. Safety Sci. 2015; 76: 190-201.

Copyright

(Copyright © 2015, Elsevier Publishing)

DOI

10.1016/j.ssci.2015.02.017

PMID

unavailable

Abstract

Learning from accidents contributes to improvement of safety and prevention of unwanted events. How much we can learn depends on how deeply we analyze the accident phenomenon. Traditional causal analysis tools have limitations when analyzing the dynamic complexity of major incidents from a linear cause and effect perspective. By contrast, systems thinking is an approach of "seeing the forest for the trees" which emphasizes the circular nature of complex systems and can create a clearer picture of the dynamic systematic structures which have contributed to the occurrence of a major incident. The "7.23" Yong-Tai-Wen railway accident is considered to be the most serious railway accident in Chinese railway history and this research analyzed the accident using the systems thinking approach. From the national accident investigation report, the system elements were identified and the causal loop diagram was developed, based on the system archetype of "shifting the burden". For the problem symptoms in the accident report, the causal loop diagram not only illustrated their symptomatic solutions, but also identified their fundamental solutions. Disclosing how an underlying systemic structure finally resulted in a major accident assists the reader to prevent such accidents by starting from fundamentals.