1. Introduction
Safety canbeviewedasacontrolproblemandsafetymustbe
managedbyacontrolstructureembeddedinsocio-technical
and complexsystems.Fromthisperspective,adverseemer-
gentpropertiesincomplexsystems–hazardoussituations
or accidents–havehigherpossibilitiestooccurwhenflaws
in thecontrolmechanisms(technical,human,organizational)
enabletheemergenceofunforeseenoutcomesthatgenerate
negativeconsequences(RasmussenandSvedung,2000). The
socio-technicalandcomplexsystemsaresocomplicatedthat
cannot beanalyzedbytraditionalriskanalysisdividingsys-
tem andbyidentifyingunwantedchainsofevents(Hollnagel,
2007). Resilienceengineering(RE)hasbecomeanimportant
field forsafetymanagementinsocio-technicalandcomplex
systems (Steen andAven,2011).
In aworldfraughtwithfiniteresources,irreducibleambi-
guity,andmultipleconflictinggoals,safetyiscreatedvia
proactiveresilientprocessesratherthanviareactiveobsta-
cles andbarriers(WoodsandHollnagel,2006). Furthermorean
actual challengeforsystemsafetyistoidentifythatcomplex
systems aredynamicandthatastatusofdynamicstability
sometimes maychangeintoastatusofdynamicinstabil-
ity (Adamski andWestrum,2003). REisanewparadigmfor
safety managementthatfocusesonthedevelopmentoftools
to ensurethatthesystemkeeps(orrecoversto)asafestable
state (Wreathall,2006). Also,REisthecapabilityofsystems
and organizationstoanticipateandadapttothepotentialfor
surprise andfailure(WoodsandHollnagel,2006). FromtheRE
point ofview,aresilientsystemisonethatutilizesinherent
human abilitiesintunewithengineeredsafeguardsandorga-
nizational features.Asaresult,itwillmaximizetheextent
of acontrolledmannerbothinexpectedandinunexpected
conditions (Fujita, 2006).
Safety managementsystemofaresilientorganization
should providemeanstoovercomeexpectedandunexpected
situations, allowingittomonitor,understand,reflectand
learn fromthesestrategies,perceiveemergentsafetythreats,
and feedthesebacktotherelevantactors.Failingtodothat
brings theorganizationintoareactivemode(Woods,2006).
RE alsoisasafetyapproachbasedonthemanagementofdis-
turbances before,during,andaftertheiroccurrence(Hollnagel
et al.,2006). ThegoalofREisnottoavoidtheoccurrenceofper-
turbations buttomanagethem(TaziandAmalberti,2006). In
addition, REfocusesonactiontocompensateforpoorbehav-
ior,poordesign,poorsystems,andpoorconditions(Furniss
1. บทนำความปลอดภัย canbeviewedasacontrolproblemandsafetymustbemanagedbyacontrolstructureembeddedinsocio-เทคนิคและ complexsystems Fromthisperspective, adverseemer-gentpropertiesincomplexsystems – hazardoussituationsหรืออุบัติเหตุ – havehigherpossibilitiestooccurwhenflawsใน thecontrolmechanisms(technical,human,organizational)enabletheemergenceofunforeseenoutcomesthatgeneratenegativeconsequences(RasmussenandSvedung,2000) การtechnicalandcomplexsystemsaresocomplicatedthat และสังคมไม่ beanalyzedbytraditionalriskanalysisdividingsys-tem andbyidentifyingunwantedchainsofevents (Hollnagel2007) . hasbecomeanimportant Resilienceengineering (RE)ฟิลด์ forsafetymanagementinsocio-technicalandcomplexระบบ (Steen andAven, 2011)ใน aworldfraughtwithfiniteresources, irreducibleambi-guity, andmultipleconflictinggoals, safetyiscreatedviaproactiveresilientprocessesratherthanviareactiveobsta-cles andbarriers(WoodsandHollnagel,2006) Furthermoreanchallengeforsystemsafetyistoidentifythatcomplex จริงระบบ aredynamicandthatastatusofdynamicstabilityบางครั้ง maychangeintoastatusofdynamicinstabil-ใช้งานของแบตเตอรี่ (Adamski andWestrum, 2003) REisanewparadigmforความปลอดภัย managementthatfocusesonthedevelopmentoftoolsการ asafestable ensurethatthesystemkeeps (orrecoversto)รัฐ (Wreathall, 2006) นอกจากนี้ REisthecapabilityofsystemsและ organizationstoanticipateandadapttothepotentialforเซอร์ไพ andfailure(WoodsandHollnagel,2006) FromtheREจุด ofview, aresilientsystemisonethatutilizesinherentมนุษย์ abilitiesintunewithengineeredsafeguardsandorga-คุณสมบัติ nizational Asaresult, itwillmaximizetheextentของ acontrolledmannerbothinexpectedandinunexpectedเงื่อนไข (ฟูจิตะ 2006)ความปลอดภัย managementsystemofaresilientorganizationควร providemeanstoovercomeexpectedandunexpectedเข้าใจสถานการณ์ allowingittomonitor reflectandเรียน fromthesestrategies, perceiveemergentsafetythreatsและ feedthesebacktotherelevantactors Failingtodothatนำ theorganizationintoareactivemode(Woods,2006)RE alsoisasafetyapproachbasedonthemanagementofdis -turbances ก่อน ในระหว่าง andaftertheiroccurrence (Hollnagelet al. 2006) ThegoalofREisnottoavoidtheoccurrenceofper-turbations buttomanagethem(TaziandAmalberti,2006) ในนอกจากนี้ REfocusesonactiontocompensateforpoorbehav-ior, poordesign, poorsystems, andpoorconditions (โดด
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1. บทนำ
ความปลอดภัย canbeviewedasacontrolproblemandsafetymustbe
managedbyacontrolstructureembeddedinsocio ทางด้านเทคนิค
และ complexsystems.Fromthisperspective, adverseemer-
gentpropertiesincomplexsystems-hazardoussituations
หรืออุบัติเหตุ-havehigherpossibilitiestooccurwhenflaws
ใน thecontrolmechanisms (ทางเทคนิคของมนุษย์องค์กร)
enabletheemergenceofunforeseenoutcomesthatgenerate
negativeconsequences (RasmussenandSvedung, 2000)
สังคม technicalandcomplexsystemsaresocomplicatedthat
ไม่สามารถ beanalyzedbytraditionalriskanalysisdividingsys-
andbyidentifyingunwantedchainsofevents TEM (Hollnagel,
2007) Resilienceengineering (อีกครั้ง) hasbecomeanimportant
ฟิลด์ forsafetymanagementinsocio-technicalandcomplex
ระบบ (สตี andAven 2011).
ใน aworldfraughtwithfiniteresources, irreducibleambi-
guity, andmultipleconflictinggoals, safetyiscreatedvia
proactiveresilientprocessesratherthanviareactiveobsta-
Cles andbarriers (WoodsandHollnagel 2006) Furthermorean
challengeforsystemsafetyistoidentifythatcomplex จริง
ระบบ aredynamicandthatastatusofdynamicstability
บางครั้ง maychangeintoastatusofdynamicinstabil-
ity (Adamski andWestrum, 2003) REisanewparadigmfor
managementthatfocusesonthedevelopmentoftools ความปลอดภัย
เพื่อ ensurethatthesystemkeeps (orrecoversto) asafestable
รัฐ (Wreathall 2006) นอกจากนี้ REisthecapabilityofsystems
และ organizationstoanticipateandadapttothepotentialfor
andfailure ประหลาดใจ (WoodsandHollnagel 2006) FromtheRE
จุด ofview, aresilientsystemisonethatutilizesinherent
มนุษย์ abilitiesintunewithengineeredsafeguardsandorga-
features.Asaresult nizational, itwillmaximizetheextent
ของ acontrolledmannerbothinexpectedandinunexpected
เงื่อนไข (ฟูจิ 2006).
managementsystemofaresilientorganization ความปลอดภัย
ควร providemeanstoovercomeexpectedandunexpected
สถานการณ์ allowingittomonitor เข้าใจ reflectand
เรียนรู้ fromthesestrategies, perceiveemergentsafetythreats,
และ feedthesebacktotherelevantactors.Failingtodothat
นำ theorganizationintoareactivemode (วูดส์ 2006) .
RE alsoisasafetyapproachbasedonthemanagementofdis-
turbances ก่อนระหว่าง andaftertheiroccurrence (Hollnagel
et al., 2006) ThegoalofREisnottoavoidtheoccurrenceofper-
turbations buttomanagethem (TaziandAmalberti 2006) ใน
นอกจากนี้ REfocusesonactiontocompensateforpoorbehav-
IOR, poordesign, poorsystems, andpoorconditions (Furniss
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