Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • apa.csl
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Menneskelig svikt vs. systemfeil: - eller noe midt i mellom?
Karlstad University, Faculty of Social and Life Sciences.
2010 (Bokmål, Norwegian; Norwegian Bokmål)Independent thesis Advanced level (degree of Master (One Year)), 10 credits / 15 HE creditsStudent thesisAlternative title
Human error vs. system failure : - or something in between? (English)
Abstract [nb]

I ulykkessammenheng går to av de vanligste undersøkelsesmetodene ut på henholdsvis å kartlegge det juridiske ansvaret for ulykken og å klarlegge årsaksforholdene. I media får vi stort sett bare høre om førstnevnte i form av oppslag om at ulykken skyldes menneskelig svikt. Årsaksforholdene tar gjerne lengre tid å kartlegge og har heller ikke elementer av helt eller syndebukk i seg, og er således mindre interessante å skrive om. I forebyggende sammenheng er det likevel gjerne her det er mest å hente. I erkjennelsen av at mennesket er og blir feilbarlig, bør man nettopp gripe tak i disse bakenforliggende årsakene, gjerne kalt latente feil, som også kan medvirke til å avverge at et tilløp får lov å utvikle seg til en ulykke. I denne oppgaven blir det gjort rede for bakenforliggende årsaker til en alvorlig samferdselsulykke på Vestlandet i 1999, nemlig hurtigbåten MS Sleipners forlis. Det blir også vist hvordan ulykken kunne vært unngått, eller i det minste at skadeomfanget kunne vært vesentlig redusert, dersom det hadde vært større fokus på å avdekke slike latente forhold. For å få offentligheten til å forstå viktigheten av slik årsakskartlegging, og ikke minst at ansvarlige instanser følger opp funnene i ettertid, er det viktig at media griper fatt i problemstillingen og setter den på dagsorden.

Abstract [en]

Two of the most common forms of investigations after accidents are the search for the judicial aspects of guilt on the one hand and the investigation to find the causes of the accident on the other hand. Media mainly tell us the result of the first one, namely that “the cause of the accident was human error”. Usually it takes more time to establish an understanding of the underlying causes. This investigation does not point out a hero, neither a scapegoat. Therefore the real causes are less interesting to the media. Still, when it comes to accident prevention, this is where one should make an effort. By recognizing the fact that humans are eligible to fail, it is here one should try to take preventive measures. By recognizing these latent conditions one may succeed to avoid potentially dangerous situations from developing to serious accidents. In this paper the underlying causes related to a serious accident that struck public transportation in Western Norway will be presented. The accident is the shipwreck of the high speed craft MS Sleipner in 1999. It will also be shown how this accident could have been prevented, or at least how the extent of the damage could have been substantially reduced, if only latent conditions had been paid a little more attention to. To make the general public understand the importance of uncovering such latent conditions, not to say make sure that they who are responsible take action to remove these conditions, it is vital that the media put these questions on the agenda.

Place, publisher, year, edition, pages
2010. , p. 54
Keywords [en]
Human error, System failure, Normal accidents, Organisational accidents, Latent vs. active errors, Barriers, Redundancy, AcciMap
Keywords [nb]
Menneskelig svikt, Systemfeil, Normal accidents, Organisasjonsulykker, Latente vs. aktive feil, Barrierer, Redundans, AcciMap
Identifiers
URN: urn:nbn:se:kau:diva-5328OAI: oai:DiVA.org:kau-5328DiVA, id: diva2:297017
Presentation
(English)
Uppsok
Social and Behavioural Science, Law
Supervisors
Examiners
Available from: 2010-02-24 Created: 2010-02-18 Last updated: 2010-02-24Bibliographically approved

Open Access in DiVA

fulltext(567 kB)7486 downloads
File information
File name FULLTEXT01.pdfFile size 567 kBChecksum SHA-512
fdc9154108614e44888e5b2db4354a343c5d5c47b6b512b8b6905c24dd2e9931d00f4017ca39b5fb1df2c8215977a4e351e24a0ab4bd87c0589377fe32d60415
Type fulltextMimetype application/pdf

By organisation
Faculty of Social and Life Sciences

Search outside of DiVA

GoogleGoogle Scholar
Total: 7486 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

urn-nbn

Altmetric score

urn-nbn
Total: 4360 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • apa.csl
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf