Analysis of the Subjects' Behavior Mechanism of 7·23 High-speed Rail Accident Based on Systems Thinking

One of the key purposes of accident investigation and analysis is to identify the accident mechanism and effective preventive measures and to improve the overall effectiveness of safety,health and environment management. However,traditional causal analysis models and tools have serious limitations when used for analyzing dynamic complexities of major incidents in view of linear causes and effects.In contrast,systems thinking is an approach of"seeing the forest while seeing the trees"which emphasizes the circular nature of complex systems and commits itself to depicting dynamic systematic structures which have contributed to the occurrence of major incidents."7.23"Yong-Tai-Wen Railway Accident has been considered to be one of the most serious railway accidents in China.This paper aims to analyze the accident by utilizing systems thinking approach according to the official accident investigation report.When system elements are identified,the paper builds four causal loop diagrams of main subjects based on the system archetype of"fixes that fail".For the subjects in the accident report,the causal loop diagrams illustrate their behavior mechanisms which reveal how a latent systemic structure finally results in a major accident and identify their respective attributes to"7.23"Yong-Tai-Wen Railway Accident.Furthermore,the paper proposes some effective preventive measures according to the analytical results to help prevent such accidents fundamentally.