Study on Developments in Accident Investigation Methods: A Survey of the "State-of-the-Art

Available on: http://www.stralsakerhetsmyndigheten.se/Global/Publikationer/Rapport/Sakerhet-vid-karnkraftverken/2008/SKI-Rapport-2008-50.pdfSKI Report 2008:50 (Swedish Nuclear Power Inspectorate) - ISSN 1104-1374The objective of this project was to survey the main accident investigation methods that have been developed since the early or mid-1990s. The motivation was the increasing frequency of accidents that defy explanations in simple terms, for instance cause-effect chains or “human error”. Whereas the complexity of socio-technical systems is steadily growing across all industrial domains, including nuclear power production, accident investigation methods are only updated when their inability to account for novel types of accidents and incidents becomes inescapable. Accident investigation methods therefore typically lag behind the socio-technological developments by 20 years or more

Accident analysis models and methods: guidance for safety professionals

Accident analysis models and methods provide safety professionals with a means of understanding why accidents occur. Choosing an analysis technique is, however, not a simple process. A wide range of methods are available; each offering various theoretical and practical benefits and drawbacks. Furthermore, individuals engaged in accident investigation are subjected to various factors, e.g. budgetary and time constraints, which can influence their selection and usage of an analysis tool. This report is based on an extensive review of the accident analysis literature and an interview study conducted with 42 safety experts and has two aims. Firstly, it provides an overview of the available analysis techniques and the factors influencing an individual’s choice and usage of these methods. The intention is to provide the reader with information that may enable them to make a more informed selection of analysis tool. The second aim is to present an analysis model currently used in industry. The intention is to provide the reader with a validated method that can be readily employed, if undertaking a detailed assessment of the available techniques is not practicable

A study on marine accident causation models employed by marine casualty investigators / by Fatoumatta Cassama

This research highlights relevant issues related to marine casualties and presents an overview on casualty investigation, a review of marine accidents, the regulatory framework on marine casualty investigations, a brief discussion on system’s design complexity and coupling characteristics, accident causation models used in casualty analysis and the marine accident investigation organizations. The principal objective of the study was to identify and evaluate marine casualty investigators’ endeavors of determining causes of a marine accident with the help of accident causation models or investigation procedures involving accident causation models. The study therefore focuses on the marine accident causation models one could utilize for conducting investigation into marine accidents. States establish an accident investigation regime to determine why an accident happened and to learn lessons that prevent similar accidents from happening in the future. The overall approach towards the research methodology was to employ mixed methods to complement the data as well as to obtain increased response from the target group. In pursuance of this goal, a mixed methods approach comprising questionnaires and structured interviews was adopted towards data collection for the study. The models applied by practitioners ranged from none to a plethora of models. The SHEL and Reason’s Swiss cheese model were common to the questionnaire respondents and interview participants while the other models mentioned were the ATSB, IMO-MAIIF, HTO, FRAM, AcciMap, MTO, ISIM and Heinrich’s Domino model. The utilization of event and causal factors diagrams was also mentioned along with path dependency. This highlights the diversity in the available models. The reasons the participants gave for the utilization of models largely depended upon the ability of the model to capture maritime accidents including complex accidents and the level of training required in the application of the model. The ability of the model to address organizational aspects rather than mechanical failures was highlighted. Also highlighted was the juxtaposition of models – that is utilizing a model to identify the technical aspects of the accident and another to explore how it was managed. Another reason highlighted was the requirement by organizations which mandated a particular model to be used. Various reasons have been stipulated by these marine accident investigators for their preferences of using particular models or none at all. The reduction of marine accidents in the maritime industry as a result of the use of models or not, is in conclusive

Overview of pedal cyclist traffic casualties in South Australia

Characteristics of pedal cycle crashes (as reported to the police) in South Australia, and how they have changed over the period 1981-2004, are examined. The paper describes both the present situation (2001-2004) and how it has changed since 1981; both child and adult casualties; both the numbers of casualties and the proportions seriously injured; and both factors that are commonly tabulated and some that are relatively unusual. In 1981, pedal cyclist casualties were mostly children and teenagers, but in 2004, pedal cyclist casualties were mostly spread across the age range from 16 to 49. Child pedal cyclist casualties reached a maximum in 1982-1987, and have fallen sharply since. Adult pedal cyclist casualties reached a maximum in 1987-1990, and then fell. Concerning the proportion of casualties seriously injured (i.e., killed or admitted to hospital), in 2001-2004 this proportion among adults (16+) was 12% when the speed limit was 60 km/h or less, and 33% when the speed limit was 70 km/h or higher. Among the four most frequent types of crashes (right angle, side swipe, right turn, and rear end), the proportions of adult casualties seriously injured were 11%, 11%, 16%, and 18%. The proportion was 14% for male drivers of the motor vehicle and 9% for female drivers; it was 17%, 15%, 15%, 14%, 10%, and 11% for motor vehicle driver age groups 16-19, 20-29, 30-39, 40-49, 50-59, and 60-99.T. P. Hutchinson, C. N. Kloeden, and A. D. Lon

The changing nature of risk

http://www.ergonomics.org.au/downloads/EA_Journals/EA_March_June_08.pdfInternational audienceThe crucial change that took place in the 19th century was that accidents became associated with the technological systems that people designed, built, and used as part of work, in the name of progress and civilisation. Suddenly, accidents happened not only because the people involved, today referred to as people at the sharp end, did something wrong or because of an act of nature, but also because a human-made system failed. Furthermore, the failures were no longer simple, such as a scaffolding falling down or a wheel axle breaking. The failures were complex, in the sense that they usually defied the immediate understanding of the people at the sharp end. In short, their knowledge and competence was about how to do their work, and not about how the technology worked or functioned. Before this change happened, people could take reasonable precautions against accidents at work because they understood the tools and artefacts they used sufficiently well. After this change had happened, that was no longer the case

Impact of the Functional Resonance Analysis Method (FRAM) in safety management at healthcare organisations

Patient safety events are likely to be one of the ten leading causes of death and disability in the world (World Health Organization, 2020). To manage safety, healthcare organisations have traditionally focused on identifying failures, performing analysis of events, and developing strategies to reduce the failures. Several thought leaders have argued that the traditional method is not adequate to manage safety in a complex environment. Their argument is that safety management should not solely focus on what went wrong, it should also include efforts which enable things to go right more often. If healthcare organisations want to broaden their approach towards managing safety, suitable methods must be investigated. The Functional Resonance Analysis Method (FRAM) was developed by Hollnagel in 2004 and has been applied in high-risk industries such as railway, aviation, maritime and healthcare. FRAM investigates the interaction of the different functions within a complex, underspecified system, and improves the understanding of normal work and its variability (Hollnagel, 2012). This systematic review will assess the application of FRAM in healthcare settings to develop a rich understanding of the application of FRAM in healthcare as a complementary method to safety management. Firstly, understanding how FRAM was implemented within healthcare organisations and secondly understanding how healthcare organisations have perceived the value-add of FRAM in terms of safety management. The results are expected to provide healthcare organisations with guidance on applying the FRAM and demonstrate the value it potentially adds to safety management. In the studies reviewed, FRAM was applied in a wide variety of settings and in different contexts. Thematic value-added aspects were identified and discussed. Shortcomings and prerequisites for the application of FRAM was also highlighted. This dissertation wishes to motivate healthcare organisations to investigate and apply alternative methods such as FRAM to enhance their ability to manage safety in a complex environment

Innovation and design change strategies for learning technologies at Warwick : towards a ‘design capabilities’ heuristic for guiding practice and evaluating change.

This report gives a narrative account of an investigation into design and design capability in teaching and learning in a research-intensive university. It begins, in the Introduction, with definitions of key concepts: design, designing, successful design (achieving fit, stick, spread and growth), design change and design capability (although this last term is only really fleshed­out in Reading the Case Studies and the Conclusion). These words are common currency, but rarely used with precision. When clearly defined they provide a lens through which we can attain more clarity and granularity in analysing attempts at enhancing practice. In the second part, on the Origins of the Investigation and Earlier Experiments, we examine the limitations of a techno­centric approach to understanding, predicting and supporting the uptake of technology enhanced learning. It is argued that a design capability approach is needed, in which the ability of all people (including students) to discover, create, adopt, adapt designs that fit, stick, spread and grow is of prime value. In part 3, the design of the investigation is explained, with its focus upon discovering, creating and using design patterns as a key facilitating aspect of design capability. In part 4, this is put to the test, with an attempt at creatively reading the 23 mini case studies produced in interviews with academics. However, design patterns do not emerge easily from the cases, and we see that design and designing in this setting is more diverse and complex than expected. It is argued that a design patterns based approach will be useful, but much more work needs to be done before design patterns can become the lingua franca of teaching and learning design and development. This leads to a more sophisticated view of design capability, presented in the Conclusion. Drawing upon the experiences of the academics interviewed in the case studies, especially experienced and confident senior academics, it is conjectured that we need to increase the intensity with which academics encounter and reflect upon design challenges, designerly approaches, suboptimal and successful designs and design patterns. An integrated combination of Design Thinking and the Higher Education Academy Fellowship framework is recommended as a way of achieving this

Establishing cost-effective safety management for major oil and gas exploitation projects in the design phase

Disasters such as Deepwater Horizon in the Gulf of Mexico, in April 2010, continue to blight the oil and gas industry despite a significant amount of research effort carried out by academia, regulatory bodies, and oil and gas companies to understand how safety-related incidents, especially disasters, can be prevented. While these have contributed to the discussion around reducing risk, they often lack the systemic influences that determine the value drivers affecting decision-making, and the ability to achieve continuous and sustainable improvements in safety performance. Consequently, this research aims to provide a more holistic approach to understanding the nature of disasters in the oil and gas industry, and identifying how future disasters can be prevented by establishing "more cost-effective strategies. Quantitative research was carried out to determine the type and validity of the data used to construct trends in major accident safety performance, and qualitative research was carried out to assess the key factors that influence safety performance, and whether these are effectively applied. The conclusions of this research are that the industry has not demonstrated effective implementation of an Occupational Health and Safety Management System (OH&S-MSj. Historically safety performance shows wide annual variations where trends are difficult to define and extrapolate, making it difficult to provide any significant benefit for major accident prevention. There is no evidence to indicate that moving from a prescriptive, to a goal-setting regime, has improved safety performance, and reduced the prospect of future major accidents. Disaster investigation reports have shown that the role of the regulator has been ineffective. However, the adoption of a more comprehensive, and effective approach to inherently safer designs, and the way projects are managed, have the potential to make safety management more cost-effective and reduce the prospect of future disasters