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Effective recommendations in loosely coupled accident investigations

Published: 28 August 2007 Publication History

Abstract

Motivation -- In many accident investigations, the investigating agency does not directly effect changes in the system investigated, and does not dictate the changes to make. Instead, the recipients of recommendations implements changes as they see fit. In such systems, acceptance of the recommendations by the target organization is vital. In this paper we describe how investigators in the Swedish Accident Investigation Board characterize effective and acceptable recommendations.
Research approach -- Interviews were conducted with seven accident investigators at the Swedish Accident Investigation Board.
Findings/Design -- Three of the investigators adapt their recommendations to the safety maturity, as they view it, of the recipient organization. Five of them emphasized the need for communication with the recipient organization, during the course of the investigation, or at the end, to facilitate understanding. All of them considered the cost / benefit of their recommendations.
Originality/Value -- This research fills an important gap regarding our knowledge about the step from analysis to recommendations in accident investigations.
Take away message -- Safety maturity, communication with recipient organizations, and cost / benefit are important values to consider when issuing recommendations in loosely coupled accident investigation systems.

References

[1]
Amalberti, R. (2006). Optimum System Safety and Optimum System Resilience: Agonistic or Antagonistic Concepts? In E. Hollnagel, D. D. Woods & N. Leveson (Eds.), Resilience engineering: concepts and precepts (pp. 253--271). Aldershot: Ashgate.
[2]
Dekker, S. (2002). The field guide to human error investigations. Aldershot: Ashgate.
[3]
Heinrich, H. W. (1928). The Origin of Accidents. The Travelers standard, 16(6), 121--137.
[4]
Heinrich, H. W. (1931). Industrial accident prevention: a scientific approach (1 ed.). New York: McGraw-Hill.
[5]
Johnson, C. W. (2003). Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting. Glasgow, Scotland: University of Glasgow Press.
[6]
US Departmend of Labor. (1920). Standardization of Industrial Accident Statistics. Washington: U. S. Department of Labor, Bureau of Labor Statistics.
[7]
Leveson, N. (2002). System Safety Engineering: Back To The Future. Massachusetts Institute of Technology.
[8]
Linell, P. (1994). Transkription av Tal och Samtal: Teori och praktik. Linköping: Linköping University: Department of Communication Studies.
[9]
Lundberg, J., & Johansson, B. (2006). Resilience, Stability and Requisite Interpretation in Accident Investigations. Proceedings of the 2nd Symposium on Resilience Engineering, Juan-les-Pins, France, November 8--10, pp 191--198.
[10]
Miles, B., Matthew, & Huberman, M., A. (1994). Qualitative Data Analysis: An Expanded Sourcebook. Thousand Oaks, CA: Sage.
[11]
Perrow, C. (1999). Normal accidents: living with high-risk technologies. Princeton, NJ: Princeton University Press.
[12]
Reason, J. (1990). Human error. Cambridge: Cambridge Univ. Press.
[13]
Reason, J. (1997). Managing the risks of organizational accidents. Burlington, VT: Ashgate.
[14]
Rollenhagen, C. (1997). Sambanden människa, teknik och organisation: en introduktion (2 ed.). Lund: Studentlitteratur.
[15]
Rollenhagen, C. (2003). Att utreda olycksfall - Teori och praktik. Lund: Studentlitteratur.
[16]
Strauch, B. (2002). Investigating Human Error: Incidents, Accidents, and Complex Systems. England: Aldershot: Ashgate.
[17]
Turner, B., A. (1978). Man-Made disasters. London: Wykeham.

Cited By

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  • (2023)Exploring the Influencing Factors of Safety Recommendations' Effectiveness in Indonesian General AviationTransactions on Transport Sciences10.5507/tots.2023.01214:3(4-15)Online publication date: 13-Dec-2023

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cover image ACM Conferences
ECCE '07: Proceedings of the 14th European conference on Cognitive ergonomics: invent! explore!
August 2007
334 pages
ISBN:9781847998491
DOI:10.1145/1362550
Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for components of this work owned by others than ACM must be honored. Abstracting with credit is permitted. To copy otherwise, or republish, to post on servers or to redistribute to lists, requires prior specific permission and/or a fee. Request permissions from [email protected]

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  • The British Computer Society
  • ACM: Association for Computing Machinery
  • SIGCHI: Specialist Interest Group in Computer-Human Interaction of the ACM
  • Interactions, the Human-Computer Interaction Specialist Group of the BCS
  • Middlesex University, London, School of Computing Science
  • European Office of Aerospace Research and Development, Air Force Office of Scientific Research, United States Air Force Research Laboratory
  • EACE: European Association of Cognitive Ergonomics
  • Brunel University, West London, Department of Information Systems and Computing

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Association for Computing Machinery

New York, NY, United States

Publication History

Published: 28 August 2007

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  1. accident investigation
  2. recommendations

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ECCE07
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ECCE07: European Conference on Cognitive Ergonomics 2007
August 28 - 31, 2007
London, United Kingdom

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View all
  • (2023)Exploring the Influencing Factors of Safety Recommendations' Effectiveness in Indonesian General AviationTransactions on Transport Sciences10.5507/tots.2023.01214:3(4-15)Online publication date: 13-Dec-2023

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