Management of Precursors

许多事故是由一系列事件造成的，即"事故链"，事件发生的方式正好，或者更恰当地说，正好是错误的。 在事故之前和导致事故的事件被称为"前兆"，它们代表了预测极端事件、评估风险暴露和确定适当的风险缓解措施的丰富信息来源。由于前兆事件可以用于理解和减轻未来的风险暴露，因此行业已经开发了用于检测、建模和对前兆信号采取行动的分析技术和管理方法。 这些工业方法在很大程度上是彼此孤立地开发的，并且跨行业的方法的授粉受到限制。 这项研究将提供一个跨行业共享事故前兆方法的平台，并将确定前兆管理的未来研究方向和挑战。 这项研究将由来自风险管理和工程界的专家委员会进行，将分析航空、化工、医疗保健和核工业等领域的前兆方法。 这些行业都面临着缓解低概率、高影响事件的共同挑战，但它们之间的差异很大，因此在发展过程中，跨行业共享的方法也很有限。这项研究将包括文献审查、专家证词、两个讲习班、委员会审议和其他实况调查活动。 该研究将最终在国家工程院的共识报告，其中包括委员会的调查结果和研讨会的会议记录。该报告将：1.提出了一个框架，了解前兆事件的背景下，事故序列。 该框架将具有跨行业适用性，并与当前行业惯例保持一致。 2.重点介绍了前兆建模方面的研究成果，并提出了未来的研究方向和挑战.审查强制性和自愿报告制度在获取前体数据方面的成功情况。 该报告将介绍可能影响这些系统性能的因素、政策和方法。4.提出了成功和设计预警系统的自动化检测和诊断的前兆事件的挑战。 该报告将为行业从业人员、风险管理和安全科学研究人员、决策者和公共部门机构提供关于使用前体减少风险的指导。 据设想，该报告将有利于广泛的行业和学科，以减轻对事件可能很少，如果有的话，直接经验。

Many accidents result from a series of events, "an accident chain", with events occurring in just the right, or more aptly, just the wrong way. The events that precede and lead up to the accident are termed "precursors," and they represent a rich source of information to project extreme events, assess risk exposure, and determine appropriate risk mitigation measures.Because precursor events can be used to understand and mitigate future risk exposure, industries have developed analytical techniques and management approaches for detecting, modeling, and acting on precursor signals. These industry methods have been developed largely in isolation from each other and pollination of methods across industries has been limited. This study will provide a platform for sharing accident precursor methodologies across industries, and will scope future research directions and challenges in precursor management. The study, to be conducted by a committee of experts from the risk management and engineering communities, will analyze precursor methodologies in the airline, chemical, health care and nuclear industries, among others. These industries face the common challenge of mitigating against low-probability, high-impact events, yet are dissimilar enough such that approaches have evolved with limited cross-industry sharing. The study will include a review of the literature, expert testimony, two workshops, committee deliberations and other fact-finding activities. The study will culminate in a National Academy of Engineering consensus report that incorporates committee findings and workshop proceedings. The report will:1. Present a framework for understanding precursor events in the context accident sequences. This framework will have cross-industry applicability and be consistent with current industry practices. 2. Highlight research findings in modeling precursors and present future research directions and challenges.3. Examine the success of mandatory and voluntary reporting systems in capturing precursor data. The report will present the factors, policies, and methods that can affect the performance of these systems.4. Present the successes and challenges of designing warning systems for the automated detection and diagnosis of precursor events. The report will provide industry practitioners, researchers in risk management and safety science, policy makers, and public-sector agencies with guidance on using precursors for risk mitigation. It is envisioned that the report will benefit a broad range of industries and disciplines in mitigating against events for which there may be little, if any, direct experience.