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Cause-effect chain from 1919 to present and some discussions
热度 1 Greg66 2017-11-2 09:40
Cause-effect chain from 1919 to present and some discussions 关于瑞士奶酪模型 SCM和 24Mode的一点讨论。奶酪模型的第四块奶酪(高层):第一版写的是 decision makers(人)及其 plant or corporatemanagement(管理活动,即动作); fallible decisions(结果);第二版是 process=access+organize+manage( =design+build+operate+maintenance+communicate);第二版后来又改写为 decisions、 process、 culture;第三版的第四奶酪写为 organizational factors。三个版本的第四模块,有人、有动作、也有结果(三种东西都有)。 24Model的各个模块(也可叫奶酪)都是动作的结果(只是一种东西):文化的水平、体系的质量、能力的大小、动作与物态的正确性。把 这几个东西都叫做“结果”也不影响他们的“行为”性质,原因是他们的作用仍然是行为 。 24Model十分明确, Reason在那个时代,对组织因素(就叫第四模块吧)是不能也没有明确具体内容的,他也一直在变化,最后只给了个含混的归纳叫做组织因素 organizational factors,具体内容说不清,说不清就难改善。上面提到, 24Model的各个模块都变成了一个东西(动作的结果),这个东西可以被评价,找到缺点,这就是 24Model把四个模块都理解为“动作的结果”的方便之处。今天这个时代,安全文化和管理体系,大家都已经知道它们是个啥了(尽管还有些局部分歧),不会像 Reason那时那么含混和在模型中常常变化了, Reason自己、 HFACS、 Salmon等对这个模块的写法都在变化,彼此不一致、不确定。 另一点重要的是,就某一个瞬时状态来说, act及其他原因模块的作用暂停、停留在这个时刻,它们之间的作用线相当于不存在,作用结果(各个模块都是作用结果)相对稳定(当然动作和物态还会对外界起作用,但其作用的正确性、方向或者格局已经被能力 capability决定了),此时 24Model上的各个原因模块间就是线性关系;就作用过程来说, act及其原因模块都在连续作用着,它们的作用线实际存在,必须画出,此时 24Model就不是线性的,而是按照圆形图循环着。所以,表格下面的两个图,一个是 24Mo del的 动态图(圆形,非线性) ,一个是 24Model的 静态图(链条形,线性) 。 关键词: 奶酪模型, 24Model ,线性,非线性 从线性到非线性:24Model可以表达其线性、也可以表达其非线性性质,看画法的不同了。 参考: (1) 事故预防科学中的几个矛盾而又统一的问题 ;(2) 24Model第五版(多图) 2017-10-31
个人分类: 1|3569 次阅读|4 个评论
What scar do you have?
JudyZhu 2015-1-17 23:10
If you are asked about the question what scar do you have, you would be probably reminded of some really dumb story behind it. When I was in grade two I poked my hand with a pencil to see how sharp it was, and then I had a small black mark in my left hand. It has faded over the years. But there is still a light grey mark I'm afraid. Nicole also got a bloody lesson of playing with a pencil sharpener yesterday. I’m afraid there would be a scar on her forefinger tip, in her left hand. She likes painting. Thus I bought lots of colored pencils and crayons for her (suitable for 0-3 years old). But they need sharpening. Later we chose a pencil sharpener (not for 0-3 years old) together in the store. It is a pocket sized, razor blade type that collects the shavings in the round green plastic housing with lovely painting of owls and flowers on it. One thing to be noticed: No matter how lovely it looks like, it is not safe for toddlers under 3 years old. I showed her how did this pencil sharpener work by spinning the pencil around making continuous contact with the razor blade. She learned fast and then she did it by herself. It seemed that she loves the schrick, schrick sound. The process was with my accompanying and was under my supervision. Nothing serious happened. But there was an accident happened yesterday afternoon. I woke up her from the afternoon nap and dressed her. She insisted playing on the bed for a while then I left the room to fetch her shoes. It was just horrible and incredible seeing the blood all over her face when I was back. I asked her what happened and why she was bleeding, but there was no answer. She looked so calm, but in nervousness. I thought the blood came from her nose. But when I quickly wiped off the blood with the facial tissue, I found it was not. When I did this, she embraced me with her arms tightly. What on earth did the blood come from? She didn’t fall. I examined all over her, found nothing. Then I noticed a small bloodstain on the bedcloth. I touched and smelled, it was fresh. I loosen her up and pulled her down sitting on my knees, and I saw the bleeding finger. It was bleeding heavily. I asked her to lift up her finger over her head, while I pressed a tissue paper on it to stop the flow, but it’s hard. I carried her and rushed to the wash room, held her finger under the running water to wash and flush out dirt. I could see it was not a big cut, but it should be a deep one because the bleeding got faster under the water flow. I pressed another tissue on her finger, and changed two more, then I had time to find a stick plaster to apply it to her finger. Finally the bleeding was stopped. Later on I had a look at the clock. The whole process took around ten minutes, but as to me, it felt like a century long. I felt that I was totally exhausted after escaping from a silent world where the only sound I could hear is the “peng-peng” of my heartbeats. I was still wondering what hurt her finger. Was there a sewing needle hidden in the bed? I put her on the sofa aisde and asked her to stay there, lifting her finger up. She followed my instructions cooperatively. Then I searched over the bed. Finally I saw the pencil sharpener beside a pillow. “There it is”, I said to myself when it caught my eyes. There was blood inside on the blade. I could imagine that the girl spinned her finger inside it as she did with a pencil. Who knows how did she get it from the high cupboard, and how did it appear on her bed! I lost my words realizing what happened. Then the following was simple. I called her caregiver asking for a leave in the afternoon. Then I called her doctor telling what happened just right now and made an appointment to have a checkup. When her doctor checked her finger in the late afternoon, I found there are actually five cuts, among which four are surfacial and one is deep. The doctor helped apply an antiseptic solution to the cuts and apply a sterile plaster to the area. Asking me to be alert for signs of possible infection such as swelling, reddening of surounding area, and oozing of pus from the wound in the next one or two days, he reassured me that it would be Ok because her tetanus immunization was up to date. It is also a lesson for me. On one hand, she is growing up every day to become a separate individual, knowing more and more about the world. But on the other, she doesn’t know what she knows is only a very small portion, while she wants to explore the world with her innocent courage. She is mostly free and spontaneous, few rules or regulations. We adults know that cause and effect are important concepts to understand when talking about accidents. It is also essential for kids to understand. I told Nicole, “See, if you spin your finger in the pencil sharpener, then your finger would be cut and bleeding. And it really hurts, right?” I think we could start with the ‘home safety lecture’ provided by the American Red Cross below. “If the balloon (1) fills with helium, then it will rise, lifting the door (2) of the mouse house. If the door (2) of the mouse house opens, then the mouse will come out onto its porch (3) and eat the cheese (4). If the cheese (4) becomes lighter in weight, then the large hand (5) will fall. If the hand (5) hits the button (6), then the button will make the horn (7) blare. If the horn (7) blares, then it will startle the cat (8) sleeping in the tree. If the cat (8) is startled, then it will fall into the basket (9) balanced on one end of the lever (10). If the lever (10) tips, then it will lift the door (11) of the woodchuck’s cage. If the door (11) of the cage opens, then the woodchuck (12) will chew on the tip of the pencil 
(13), exposing the lead. If the machine fails to sharpen the pencil, then find an ink pen (14). ” See the link below for the original post: http://blog.chinadaily.com.cn/blog-309597-26072.html
个人分类: diary: growing with my daughter|2585 次阅读|0 个评论
proximate cause 和 ultimate cause: 近因,远因,终极因?
dxd 2012-5-20 06:16
Proximate cause 和 ultimate cause,字面上可译为“近因”和“终极因”,最近带实验课的时候才接触到。其实当年自己也学过相关的概念,但没有记住这两个名词。 在生物学中谈到某个性状出现的原因时,“近因”一般指此时此刻环境、生理、生化等层次上的直接原因。例如问,亲鸟为什么给幼鸟喂食?这时可以回答:因为幼鸟张着大嘴(喙)并且发出讨食的叫声,而且幼鸟的嘴有鲜黄色的边缘,这些信号都通过亲鸟的视觉和听觉对其大脑造成了刺激,促使其作出了喂食的决定。当然,还可以辅之以更多的生理学和神经学上的细节。 而后者,也就是“终极因”,一般指该性状在其进化历史上的选择优势。比如在上例当中,其“终极因”可以这样解释:那些对幼鸟的这些刺激不产生喂食反应的个体,其后代成活率相对较小,而能够保持喂食行为的个体,其后代成活率相对较高,并且也遗传了该行为。因此在进化的历程中,具有喂食行为的个体占了上风,并最终被保留了下来。 话到这里还没完。较真的同学可能会问:“一个性状,比如这个喂食行为,到底如何进化出来的呢?上面这个解释明显还不够‘终极’嘛!” 这个问题很要命,但又表述得不太恰当。要我说,其实没有什么东西是“进化出来”的。通常我们所提到的“进化”,都只是用来解释某个性状为什么能被保留,或者为什么会被淘汰,而并不能解释它是如何从无到有出现的。一个新性状的出现,说到底应该是遗传学以及发育学的问题,有时候还涉及到生物个体(或基因/基因组)之间、以及个体与环境(遗传物质与微环境)之间的相互作用。这往往并非一个线性过程,而且每一个性状可能都有各不相同的起源,现在还无法用一个既普适、又准确的理论来概括。 而这些遗传及发育层面上的过程,最终还是要符合更底层的物理、化学规律。不符合理化规律的“性状”,是不会“进化出来”的。即使短暂出现,也不能作为一个稳态而维持,匡论接受进化力量的塑造和筛选。 有人认为,只有走入这些更底层的物理学以及化学过程,才谈得上所谓的“终极因”。我认为,系统动力学中的“稳态”这一概念,就是搭在物理世界与生命世界之间的一座桥梁,可以作为奠基在进化解释之下的、进一步的原因。 当然了,也许没有什么是“终极”的原因。人类对自然界的认识总会不停地进步,也就总会从一个层面上的“终极因”,跳往下一个层面上的“终极因”。从这个意义上讲,在生物学中,将ultimate cause译为“远因”即可,而目前也确实是这么翻译的。
个人分类: uncategorized|13691 次阅读|0 个评论

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