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Launched Aug 26 1996.
This section contains random personal musings about the investigation processes and investigation practices I have observed over the years. I hope they will be entertaining, at least.
Did you ever wonder why
in organizations that investigate accidents, their investigation productivity and efficiency have been declining or static in an era when both productivity and efficiency have been improving in almost all other organized endeavors? Hmmm.
government agencies enter into research projects when something is not understood about an accident, instead of putting the research burden on those entities who should know in order to fulfill their operational and management obligations in the first place?
investigation organizations are so reluctant to predict the safety effectiveness of their proposed actions, and how that effectiveness will be recognized?
investigators raise the level of abstraction when they have to describe events they do not understand - especially in the human factors arena?
there isn't anyone - beside litigants or salesmen - who is willing to ague the merits of probable cause or root cause determination as investigation objectives??
- so many managers, operational types and designers seem to give lip service only to investigation programs until something really bad happens?
with the advances in predictive analyses used in system safety programs for products, investigations are not always used to update or upgrade these analyses?
an accident or fire or explosion or spill is still referred to as an event rather than a process, and what difference the answer makes to investigators?
- so much investigation and accident causation literature is generated by practitioners of disciplines other than researchers educated as practitioners of the investigation discipline?
In the USA, a 1996 amended law made data used to support government-sponsored studies available to the public under Freedom of Information requests. It will be interesting to watch how that law is implemented.
My own first experience with such a request has been greeted by delay until the final study is released. Of course, by then any damage due to inadequate or inappropriate underlying data will have been done, because corrections always get a lot less attention than the original releases.
Pity there is no peer review requirement for such research.