Translating Systems Thinking into Practice: A Guide to Developing Incident Reporting Systems
暫譯: 將系統思維轉化為實踐：開發事件報告系統的指南

The objective of this book is to provide practical guidance on developing and implementing incident reporting and learning systems that are underpinned by the latest ’systems thinking’ on accident causation and prevention. Although the systems approach to accident causation is now well known (e.g. Dekker, 2011; Reason, 1990; 1997; 2008), the extent to which incident reporting and learning systems used in safety-critical domains incorporate systems thinking is questionable. As a result, there is a notable gap between research and practice, and opportunities to develop more effective and holistic accident prevention measures are not being taken. The book begins by outlining the systems thinking in accident causation and prevention philosophy and the need for incident reporting and learning systems that are based in systems thinking. It then outlines a generic process model for developing and implementing such incident reporting and learning systems within safety-critical systems.