What-You-Look-For-Is-What-You-Find - The consequences of underlying accident models in eight accident investigation manuals

Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of current knowledge - or assume - about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. In this paper the authors examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, the authors focus on accident models and in particular the assumptions about how different factors interact to cause - or prevent - accidents, i.e., the accident "mechanisms". Secondly, the authors focus on the scope in the sense of the factors (or factor domains) that are considered in the models - for instance (hu)man, technology, and organization (MTO). Thirdly, the authors focus on the system of investigation or the activities that together constitute an accident investigation project/process. The authors found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the 'What-You-Look-For-Is-What-You-Find' or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called 'What-You-Find-Is-What-You-Fix' or WYFIWYF principle.

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  • English

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  • Accession Number: 01142870
  • Record Type: Publication
  • Files: TRIS
  • Created Date: Sep 28 2009 12:17PM