Management of Precursors

许多事故都是由一系列事件造成的，这就是“事故链”，事件发生的方式恰到好处，或者更贴切地说，只是以错误的方式发生。事故发生之前和发生前的事件被称为“前兆”，它们代表着丰富的信息来源，用于预测极端事件、评估风险暴露和确定适当的风险缓解措施。由于前兆事件可用于了解和减轻未来的风险暴露，各行业已开发出分析技术和管理方法，用于检测、建模和处理前兆信号。这些行业方法在很大程度上是在彼此孤立的情况下开发的，跨行业的授粉方法一直受到限制。这项研究将提供一个跨行业共享事故前兆方法的平台，并将探讨前兆管理的未来研究方向和挑战。这项研究将由一个由风险管理和工程界专家组成的委员会进行，将分析航空、化工、医疗保健和核工业等行业的前体方法。这些行业面临着缓解低概率、高影响事件的共同挑战，但差异很大，以至于方法演变成了有限的跨行业共享。这项研究将包括对文献的审查、专家证词、两个讲习班、委员会审议和其他实况调查活动。这项研究将最终形成一份国家工程院共识报告，其中纳入了委员会的调查结果和研讨会记录。该报告将：1.提出一个在事故序列背景下理解前兆事件的框架。这一框架将具有跨行业的适用性，并与当前的行业实践保持一致。2.重点介绍了前兆建模方面的研究成果，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捕获前体数据方面的成功。报告将介绍可能影响这些系统性能的因素、政策和方法。介绍了为前兆事件的自动检测和诊断设计预警系统的成功和挑战。该报告将为行业从业者、风险管理和安全科学研究人员、政策制定者和公共部门机构提供使用前体缓解风险的指导。据设想，该报告将使广泛的行业和学科受益于减轻对可能几乎没有直接经验的事件的影响。

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.