What you find is not always what you fix—How other aspects than causes of accidents decide recommendations for remedial actions

Abstract

Abstract:In accident investigation, the ideal is often to follow the principle "what-you-find-iswhat-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.

Systemic accident analysis: Examining the gap between research and practice

“…Johnson, 2003;Lundberg et al, 2010). These influences can arguably lead practitioners away from the theoretical ideal of accident investigation and therefore contribute to a research-practice gap (Lundberg et al, 2010).…”

“…Underwood and Waterson, 2012), it is believed that practitioner-related influences, such as those described by Lundberg et al (2010), require further examination within the context of SAA. Therefore, the following aims for the study were established:…”

Implementing recommendations from accident investigations: A case study of inter-organisational challenges

“…In previous studies of challenges to implementation, the process has been analysed from a relatively one-sided perspective. For example, Lundberg et al (2010; studied challenges to implementation from the investigators' perspective. Although this is a valuable viewpoint, it leads to a somewhat incomplete description of the difficulties related to making safety improvements in multi-organisational settings.…”

“…The vast amount of different methods for accident investigation can be seen as an indication that development of new methods is the "holy grail" of systems safety research (Lundberg et al, 2010). However, the investigation is only a first step to achieve safety improvements.…”

“…that they are implemented. Whereas a lot of research has dealt with challenges related to accident investigation and the methods used in this step, limited focus has been given to the implementation of recommendations (Lundberg et al, 2010;Carroll and Fahlbruch, 2011). This process therefore merits further attention.…”