電気作業員の死亡事故における検視官による調査：システム思考の視点

Objectives. Electrical work remains a dangerous occupation in Australia and around the world. Despite industry regulations and technological safety advancements, serious electrical incidents involving electrical workers, including electrical fatalities, continue to occur. Systems thinking approaches predict that incidents such as these are complex system problems caused by multiple factors at a range of system levels, rather than simply caused by worker error. Methods. This study extracted causal factors identified in 11 Australian coroner reports investigating electrical fatalities involving electrical workers. Extracted factors and inter-relationships were mapped on an AcciMap to identify where in the system the factor occurred and tested against the key predictions of Rasmussen's risk management framework (RMF), a systems thinking framework. Results. Causal factors of electrical incidents involving electrical workers were found to be numerous and extend to system levels beyond the front-line worker. Evidence within the coroner reports supported each of the seven key predictions of the RMF. Conclusion. This study identifies the electrical industry as a complex socio-technical system and determines that electrical incidents involving electrical workers are therefore complex systems problems. Recommendations are made for the adoption of systems thinking frameworks in electrical incident investigations, policy and preventative strategy development, and associated research.