危险状态和事故
Hazardous States and Accidents

原始链接: https://entropicthoughts.com/hazardous-states-and-accidents

在复杂系统中维持安全依赖于持续管理约束,以应对不可预测的环境因素。这并非通过预编程步骤实现,而是通过**动态控制**——一个持续的观察、预测和行动循环。 多个“控制器”通过接收系统当前状态的**反馈**,利用**心理模型**预测未来状态,并发出**控制动作**来相应调整,从而防止危险状况。 当这些组件中的任何一个不足时,就会发生故障:缺乏准确的信息(反馈)、糟糕的预测(心理模型)或无效的调整(控制动作)。这些问题可以独立存在,也可以组合出现,有时甚至表明缺少控制器。 控制器在各个层面运作,从发动机控制等自动化系统到飞行员、主管甚至监管机构等人类因素——这表明安全是一个多层次、不断适应的过程。

对不起。
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原文

Hazardous conditions, as we have seen, are defined by constraints. To stay out of hazardous conditions, we have the system maintain such safety constraints. In general, though, the environment often tries to tip the system into breaking these constraints, and it often does this in unpredictable ways. This means we cannot declare in advance a sequence of steps the system should follow that will always maintain constraints.

Instead, maintaining constraints is a dynamic control problem. There are multiple controllers interacting with the system to try to keep it out of hazardous conditions. They observe feedback, i.e. information on where the system is now; they execute mental models, i.e. run simulations of where the system is going in the future; and then they issue control actions, i.e. try to adjust the system to maintain constraints based on their predictions.

Whenever a system enters a hazardous condition, it is because there were problems with the control structure, specifically one of the three components listed above:

  • Feedback to controllers can be insufficient, which means the controllers do not understand what is going on with the system at some specific moment.
  • Mental models can be insufficient, which means the controllers understand what’s going on with the system, but they are unable to predict something that will happen in the future.
  • Control actions can be insufficient, which means the controllers know what they need to do to the system to maintain constraints, but it does not have an effect of the desired strength.3 This could be because the effect is too weak – or too strong!

We can also see combinations of these problems. When all three of them are problematic, we might actually be looking at an entire controller missing that should be present.

Controllers exist on all levels. For aircraft maintaining fuel constraints, controllers include the fadec inside the jet engines, the flight management computer, pilots, ground crew, dispatchers at the airline, training programmes for pilots, air traffic controllers, as well as national and international regulatory boards.4 For my child among rocks, controllers include their balance, their strength, their extremely limited sense of self-preservation, my instruction, my supervision, the places I decide to take us, etc.

Low-level controllers are often automated, in hardware or software. High-level controllers are often social, cultural, and legal in nature.

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