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事件与事故分析

Was It Fatigue?

事故后的结构化分析，判断疲劳是否促成了某一事件，以及通过何种途径。

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A Was It Fatigue? finding on a phone: a Fatigue Accident Likelihood Score of 3.2, between Possible and Likely, with how to record it.
风险与安全解决方案

问题所在

严重事故必须调查，但很少有调查认真探究疲劳因素。

疲劳很容易被提出，却很难在事后证实。调查往往不是遗漏了它，就是在未检验其他解释的情况下把责任归咎于它。

Was It Fatigue? 为您的调查人员提供一致且可重复的探究方法，并留下记录，证明其他解释已经过检验。

See how Was It Fatigue? works Watch the video · 0:33
Presented by Professor Drew Dawson

The size of the problem

National figures for 新加坡, from published research. They are modelled, not measured in your workforce.

  • 13%of workplace injuries are linked to sleep problems2014
  • 27.6%have inadequate sleep2022 (SMHS 2016, fieldwork 2016-2018)
  • S$2,312lost productivity per affected employee each year
Sources
  1. Uehli K, et al. Sleep problems and work injuries: a systematic review and meta-analysis. Sleep Medicine Reviews, 2014.
  2. Lee YY, et al. Sleep quality of Singapore residents: findings from the 2016 Singapore Mental Health Study. Sleep Medicine: X, 2022.
  3. Rosekind MR, et al. The Cost of Poor Sleep: Workplace Productivity Loss and Associated Costs. Journal of Occupational and Environmental Medicine, 2010;52(1):91-98, applied to average earnings in Singapore (MOM, mean gross monthly income from work of full-time employed residents, 2Q 2026 preliminary, excluding bonuses).

案例

The biggest incidents fatigue played a part in

Findings from investigators, coroners and courts in 新加坡和澳大利亚 that fatigue contributed, the most harmful first.

案例以英文显示。

  • 2023年6月 · New South Wales, Australia

    Charter bus crash that killed 10: operator and directors fined $674,000 incl. fatigue management failures

    • 安全
    • 法律
    • 财务

    After a charter bus crash in regional New South Wales killed 10 people and seriously injured 25, the National Heavy Vehicle Regulator prosecuted the bus company and its two directors. They pleaded guilty to Heavy Vehicle National Law safety duty breaches covering inadequate driver recruitment, failure to manage overspeed in a timely way, and fatigue management failings. The court fined the company $650,000 and each director $12,000, with proceedings against two managers still pending.

    案例 AU-transport-23报告问题

查看所有与疲劳相关的新闻

运作方式

A structured answer to “was it fatigue?”

After an incident or near miss, investigators work through a structured method: was fatigue present, and was the error the kind fatigue produces once other explanations are tested? It sits at the last level of defence, after something has gone wrong, and feeds each finding back into the levels before it: rosters, sleep and in-shift controls.

  1. Step 01

    事件

    调查人员针对某一具体事故开启评估。

    The Was It Fatigue? investigations list on a phone, each with its Fatigue Accident Likelihood, and a button to begin a new investigation.

  2. Step 02

    当时是否存在疲劳？

    Fatigue Likelihood Score（疲劳可能性评分），基于四个问题：事发前是否刚刚睡着、事发前十五分钟内的行为症状、先前的睡眠与清醒史，以及排班中的睡眠机会。

    A new Was It Fatigue? investigation on a phone: the date of the incident, then whether there is clear evidence the person fell asleep immediately before it.

  3. Step 03

    是否属于疲劳型差错？

    Fatigue Error Likelihood Score（疲劳差错可能性评分）在将差错归因于疲劳之前，在每道防线上检验其他解释。

    Expert guidance in Was It Fatigue?: the behaviours that would support questionable evidence of fatigue in the 15 minutes before the incident, with a button to confirm the response.

  4. Step 04

    综合结论

    Fatigue Attributable Likelihood Score（疲劳归因可能性评分），以 1–5 级呈现并指明途径，结果反馈至排班、睡眠及当班控制措施。

    A Was It Fatigue? finding: a Fatigue Accident Likelihood Score of 5.0, Almost Certain, with what the score means and how to record it.

After an incident, fatigue is either missed or blamed without testing the alternatives. Neither helps the people involved, and neither tells you which control failed. I wanted investigators to have a consistent way to ask the question properly, and a record that shows they did.

Daniel Platt联合创始人兼首席执行官

Rollout

How we roll it out

  1. Scope

    Agree which events call for an assessment, and who investigates.

  2. Set up

    Investigator access, fitted to your existing incident process.

  3. Train

    Investigators learn the method and work a first case together with us.

  4. Review

    Findings feed back into roster, sleep and in-shift controls.

客户能看到什么

谁能看到什么

每份记录都会指明疲劳途径，并记录已检验的其他解释。按调查数量而非员工人数计价：这是本系列中唯一按事件计价的产品。

按流行率定价，而非按人头。 定价方式.

  • Your investigators

    The full record

    • Every answer and score
    • The alternative explanations tested
    • The fatigue pathway named

  • The employer

    One record per event

    • A structured, repeatable investigation record
    • Findings to feed back into roster, sleep and in-shift controls

证据

我们能够证明的

其设计要求同时存在疲劳和具有疲劳特征的差错，并在整个过程中检验其他解释。这正是它不会仅凭疲劳就推断因果关系的原因。

它是本系列中唯一一款在事件发生后回溯审视所有防线（包括排班是否充分）的产品。

无法证明的

它是回溯性的。它不能预测事件，不能评估群体规模，单次调查也不能确立规律。它不是经过验证的工具，我们也不对其作任何验证声明。所产生的记录可能须在法律程序中披露。

In practice

Rail · North America

A Class I railroad uses Was It Fatigue? to determine whether fatigue contributed to an incident or near miss.

Its investigators ask the same structured questions after every event, so each record assesses how likely it is that fatigue was present and that the error was the kind fatigue produces, and shows which other explanations were tested.

FAQs

Questions we’re often asked

Who uses it?

Your investigators, who open an assessment against a specific incident or near miss.

How does it avoid blaming fatigue by default?

It requires both the presence of fatigue and an error of the kind fatigue produces, and tests alternative explanations at every level before attributing an error to fatigue.

The science

What does the finding look like?

A Fatigue Attributable Likelihood Score on a 1–5 band with the fatigue pathway named, which feeds back into roster, sleep and in-shift controls.

Is it a validated instrument?

No, and no validation claim is made for it. It is a structured, repeatable method. It is retrospective: it does not predict an event, and one investigation does not establish a pattern. Records produced are discoverable.

The science

How is it priced?

On investigation volume, not headcount: it is the only event-priced product in the suite.

How pricing works

How is investigation data protected?

The platform is certified to ISO/IEC 27001:2022.

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后续路径

下一步

Was It Fatigue?与新加坡 33 个行业的法规

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与Was It Fatigue?相互关联的其他解决方案

第 2、3 道防线

Fatiguefit4Duty

在下一起事件发生前，于上岗时发现高风险。

从这里开始

Fatiguefit

将调查结果转化为覆盖整个机构的实测全貌。

Interested in Was It Fatigue? for your organisation?

Tell us a little about your organisation and which solutions you’re looking at, and our team will be in touch.

Express interest 查看您的员工队伍概览
A Was It Fatigue? finding on a phone: a Fatigue Accident Likelihood Score of 3.2, between Possible and Likely, with how to record it.