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Launched Aug 26 1996.
International Seminar, Barcelona, Spain; October 20, 1998
© Copyright, 1998 - Ira J. Rimson and Veridata, Ltd.
Veridata, Ltd.; P.O. Box 11008
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Phone & FAX: 505-275-4970
Determining accident "Causes" has been a source of ignition for arguments in the aviation community for half a century. Few today are familiar with the origins of "Probable Cause" determination in air safety investigation. Fewer still understand how this uncritically accepted objective has contaminated subsequent investigations and hindered Investigating Agencies' conjoint legislative purpose: preventing accident recurrence.
Civil aviation accident investigation in the U.S. began amid fractious political and economic environments that aspired more to reward political connection than to prevent losses. The bureaucrat-attorneys who enacted the conjoint objectives of causal determination and prevention for investigating authorities failed to establish measurable definitions against which investigations could be assessed. The resulting absence of investigative rigor has been accepted uncritically to this day. The simplicity of early aviation systems accommodated rudimentary investigative methods. The current aeronautical environment's rapidly expanding technological complexity does not. We can no longer afford to indulge in unscientific, unvalidated, unstandardized investigations, which produce unverifiable conclusions. Recommendations arising from these confusions of unsubstantiable data lack any reliable means to gauge their efficacy for preventing recurrence.
The air safety community must acknowledge what the rest of the world already recognizes: its concentration on assigning "Probable Causes" has failed to halt preventable mishaps. Historic concepts of causation have been ineffectual. An alternate definition of Cause --that of precursor (as in cause-and-effect) --affords the opportunity to create a "Calculus of Causation". The added rigor would enable establishing investigation models as benchmarks against which standard, logic-based investigations can be evaluated, verified and validated, and provide timely identification of potentially successful intervention strategies to deter repetition.
At 3:30 a.m. on May 6, 1935, TWA Flight 6, a Douglas DC-2 enroute from Albuquerque, New Mexico, to Kansas City, crashed sixteen miles south of Kirksville, Missouri, with five fatalities of the thirteen persons on board. One of the fatally injured was Senator Bronson Cutting of New Mexico. The political furor aroused by his death, and subsequent actions taken by both govern-ment and industry parties and congressional intervenors, profoundly influenced the purportedly objective investigation process. The discord which followed the Cutting Air Crash permanently dashed any expectations that air safety investigation authorities could determine causes of accidents objectively without the self-serving intervention of implicated parties. (Ko:84)
The Air Commerce Act of 1926 was the U.S. Congress's response to government's evolving role in regulating the U.S. air transportation industry. The Act charged the Secretary of Commerce with fostering air commerce, issuing and enforcing air traffic rules, licensing pilots, certificating aircraft for airworthiness, designating and establishing airways, and operating and maintaining aids to navigation. Of the seven original organizational units which made up the Aeronautics Branch of the Department of Commerce, only three had actually been part of it. Others were scattered throughout the Department; e.g., the Airways Division was assigned originally to the Bureau of Lighthouses, and the Aeronautics Research Division to the Bureau of Standards. Consolidation of the dispersed units into one organizational entity was not achieved until 1934, when the former Aviation Branch was renamed the Bureau of Air Commerce.
The Act also assigned to the Secretary of Commerce responsibilities for establishing and maintaining a "high level of safety", and to "investigate, record and make public the causes of accidents in civil air navigation." The concept of accident "causes" was thus initiated into the regulatory process by which those statutory functions were to be exercised by the government.
The death of a U.S. Senator in an air transport crash infuriated members of the U.S. Congress, especially because of perceived personal conflicts between Senator Cutting and then-President Franklin Roosevelt.
Just one week after the Cutting crash, the U.S. Senate entertained a resolution which called for the Committee on Commerce, or a subcommittee thereof, "...to investigate fully and thoroughly..." the aircraft accident that resulted in the death of "an honored member of this body" and "...any other accidents or wrecks of airplanes engaged in interstate commerce."
The Senate passed the resolution on June 7, 1935.
In the meantime, Eugene Vidal, Director of the Bureau of Air Commerce, appointed a five-member Board to investigate the crash. It questioned 59 witnesses and filled more than 900 pages of testimony, reporting back to Vidal on June 4, 1935, less than a month after the accident. The Board concluded that:
There is obviously little argument to be made with the "...probable direct cause..." determined by the Board, except that it is not a cause. It is a statement of what happened.
The Board's "contributory causes", on the other hand, were not so innocuous, including:
The Board found "...no evidence...that the established Department of Commerce navigation aids or its personnel were not functioning properly...." The Bureau subsequently found that the performance of TWA personnel constituted violations of air commerce regulations, and cited the airline and its employees for at least six violations for which the Bureau assessed civil penalties against TWA in the amount of $3500.
Both TWA's President Jack Frye and Senator Royal Copeland, who headed the sub-committee appointed to head up the investigation initiated by Senate Resolution 146, counterattacked the findings of the Bureau's Investigation Board. Frye co-opted the Copeland Sub-committee's principal technical consultant, Colonel Harold E. Hartney, whose field inquiries soon uncovered numerous witnesses along the airplane's route of flight. That the witnesses' testimony turned out to be both internally and externally inconsistent with established facts and each other, respectively, apparently did not trouble these investigators. U.S. Post Office inspectors finally were called in to verify the more spurious claims of the Copeland Sub-committee staff. After demonstrating convincingly that the original Frye-Hartney hypothesis for the accident was totally unsubstantiable, the two dropped their initial theory in favor of another of similar implausibility.
More significant for accident theorists was the testimony of Accident Board Members before the subsequent Senate hearings. Denis Mulligan, Chief of the Enforcement Division, testified that the accident "...started to happen long before the airplane reached the vicinity of Atlanta, Missouri." Likewise, R. W. Schroeder, Chief of the Air Line Inspection Service, testified that the accident started to happen when the pilot, still only a half hour out of Wichita enroute to Kansas City and knowing he was without two-way radio communication, first encountered instrument meteoro-logical conditions. Yet both TWA's Captain and dispatcher sanctioned continuation into the weather and a fruitless attempt to land at Kansas City before attempting to continue on to a suitable alternate landing field.
"They both gambled on getting into Kansas City," Mulligan concluded, "and they lost."
Public perceptions of the Bureau of Air Commerce were summed up in the following contemporaneous observations published during the conflict between the Bureau and TWA:
Aero Digest wrote: "The seriousness of this controversy cannot be overestimated. It goes right to the heart of the Government's system of regulating the aviation industry." And if TWA's claims were correct, "...they expose a hitherto hidden disease gnawing at the vitals of America's air transport, the disease of politics in its most hideous form --face saving."
The Air Line Pilots Association's President detected "...a tendency on the part of the present regulatory agency to theorize too much, and, in the absence of immediate concrete evidence, the accident is conveniently blamed on the pilot."
A Copeland Sub-committee aide reviewed the Bureau's records of Probable Cause determinations in air carrier accidents and found that "...in no case during the past ten years has the Department ever accused themselves of an accident." He concluded, "Naturally, they [Bureau personnel] have whitewashed themselves for ten years...." These apparent conflicts of interest increased the public's suspicion that high level appointments within the Bureau were based on political party affiliation rather than on merit and qualification.
No-one was very surprised when the Sub-committee's Report proved to be remarkable for its disregard for factual accuracy, its misinterpretation of events, and its unrestrained bias:
The sub-committee predictably absolved TWA of any responsibility in the accident.
President Roosevelt directed that the Secretary of Commerce "...call in and confer with a group of patriotic and widely known citizens who will cooperate with you in formulating plans for the control of this distressed situation...," which led to convening the National Accident Prevention Conference in December 1935. The Conference reported that funding cutbacks had led to the Bureau's being "...unable to keep pace with increased flying activities to such an extent that its regulation, construction, maintenance, and control of safety is scanty, and there now exists a state of critical inadequacy...." The air carriers identified deficiencies amounting to $31 million. The Bureau of Air Commerce reduced that estimate to $9 million, but the only possible source of funding could be the Public Works Administration, whose director pared the figure once again, to $5.12 million, the figure finally sent to the Bureau of the Budget. The Bureau of the Budget approved $500,000.
In December, 1936, and January, 1937, five U.S. air carrier transports crashed. Four of the accidents resulted in fatalities. On February 28, 1937, Bureau of Air Commerce Director Vidal resigned. On March 1st, the Secretary of Commerce appointed Fred D. Fagg, Jr., formerly a professor at the Northwestern University Law School, as Vidal's successor. [In July, 1936, Fagg and Dean John H. Wigmore of Northwestern University Law School had begun codifying and standardizing issuance of the air commerce regulations.] Within the year he had reorganized the Bureau functionally and invited outside participants into the accident investigation process.
More significant, Fagg was instrumental in developing and guiding the passage of the Civil Aeronautics Act of 1938, which established the Civil Aeronautics Authority as the single independent agency in change of all federal government aviation activities. The Act also established an independent Air Safety Board within the Authority. The three-man Board was completely separated from the Authority's other functions, and was empowered to investigate accidents and recommend prevention measures. The Civil Aeronautics Act established the legislative requirement for the Air Safety Board to determine Probable Cause of aviation accidents, but failed to clear up the original semantic misunderstanding which arose from the Air Commerce Act's requirement for determining "causes of accidents". According to Jerry Lederer, first Director of the CAA's Office of Aviation Safety, Fagg and Wigmore considered the principles of flight sufficiently mysterious that ascertaining the actual causes of accidents would be impossible. That skepticism led them to fabricate new applications for established legal terms of art. By neglecting to differentiate the new usages from the established lexicon, they introduced linguistic vagueness, the principal insurmountable flaw in the investigation process which survives to this day.
These three linguistic concepts are probably known abstractly to investigators, who may never have examined their application to investigations and their objectives:
These concepts should be significant to investigators, who must eliminate as much uncertainty, ambiguity and vagueness as possible during the investigation process. Both uncertainty and ambiguity can eventually be resolved by sufficient data, information and facts. Vagueness, on the other hand, cannot. A vague term is itself inherently incapable of classification; its very definition lacks sufficient precision to enable either classification or discrimination. (McFr:93)
Attempts to transpose "cause" or "probable cause" from their legal definitions to scientific applications lead to increasing vagueness and indeterminacy. No amount of additional information or data can help us identify "cause" or "probable cause". The terms fail to define what the object is we're looking for. As a result, we cannot determine what it is, where to find it, how to get to where it might be, how to recognize it if by chance we do, or how to guarantee its identity.
The concept of "Cause", as applied to the objectives of air safety investigations, evolved without definition along an inconsistent pathway:
"Cause" first appeared as a duty of the Department of Commerce in §172 of the Air Commerce Act of 1926:
"Probable Cause" materialized in the 1934 Amendment to the Air Commerce Act of 1926, which merged the formerly scattered aviation functions of the Department of Commerce's Aviation Branch into the Bureau of Air Commerce:
The Civil Aeronautics Act of 1938 established a Safety Board within the Civil Aeronautics Authority, assigning to it in §702 duties to:
The Federal Aviation Act of 1958 established both the Federal Aviation Administration and the Civil Aeronautics Board, assigning to the CAB responsibility for "...the promotion of safety in air commerce." A duty of the CAB specified in §701 was to:
The Department of Transportation Act of 1966 established the Department of Transportation, interposing it as a managerial layer superior to the FAA; and the National Transportation Safety Board. In §5 it established the duties of the NTSB, including:
The Independent Safety Board Act of 1974 established the NTSB as an independent agency of the U.S. federal government, and established among its duties in §304:
As the duties of successive investigative agencies evolved from determining "cause" to "probable cause" to "cause or probable cause" to "cause or probable cause or causes", agency managers and investigators were denied enlightenment by the absence of any more comprehensive statutory definitions of "cause" or "probable cause". A 1942 description of the CAA Air Safety Board 's interpretation of "probable cause" by Jerome F. "Jerry" Lederer, then its Director, has survived:
I don't find that much help. Both "proximate cause" and "probable cause" are legal terms of art; i.e., they possess specific meanings within the context in which they are applied. The two terms are defined as follows in their legal applications:
If we attempt to apply the terms "proximate cause" and "probable cause" in an investigation context using their legal definitions, Lederer's interpretation lacks coherence. Worse yet, these legal definitions add the following vague abstractions to the original confusion:
as well as still more undefined concepts of cause:
Rules of law often retain some vagueness to permit flexibility in applying them to unforeseen circumstances. (CoCo:90) Equivocation has utility for an attorney attempting to prove or refute the elements of legal proof required to convince a jury of a client's guilt or innocence. However, that elasticity is not conducive to scientific hypothesis testing. By choosing determination of undefined "causes" or "probable causes" as their principal investigation objective, investigation authoritiies create a quandary for investigators who attempt to apply objective methodologies to the study and understanding of how accidents happen. In the absence of any more precise definitions against which to measure their conclusions, it is impossible for investigators to "determine" the "causes" or "probable causes" of mishaps. In fact, within the U.S. NTSB "causes" or "probable causes" are assigned administratively by visionaries far removed from the investigation process.
The laxity of logical rigor imposed on categorical assignments of "cause" and "probable cause" permit designations which defy rational credibility, e.g.:
The obvious logical flaws in these examples are apparent. However, similarly flawed evaluations are not so obvious when readers do not analyze the detailed investigation process and the facts which it purports to reveal. Let us take as an example some early causal arguments which arose following the crash of Korean Air Flight 801 on approach to Agana, Guam, M.I. On the day of the crash (August 6, 1997), a KAL vice-president announced on network television (CNN) that weather and the lack of an operative glide slope on the instrument approach were the "causes" of the accident. In a report two days later, CNN reported that the airline "angrily denied" that pilot error was a factor. Ladkin comments on these statements after analyzing their logic considering other facts known at the time:
For the past sixty years the U.S. government's aviation accident investigative authorities have been charged with three specific objectives:
From its outset the CAA's Air Safety Board chose to elevate the task of determining cause(s) or probable cause(s) to preeminence. That choice apparently has never been seriously questioned. Succeeding organizations have maintained the priority of determining causation even as it has become obvious that many assigned "cause(s)" cannot be substantiated by the facts, conditions and circumstances of the individual case. "Cause" is, by definition, vague; "probable cause" is even more vague. Accidents are the concluding events of processes which are frequently complex, having generated over an extended time period. Prerequisite conditions may have been established years or decades before.
One, or several, "probable cause(s)" cannot account for accidents' complex evolutionary process. The NTSB developed a predetermined menu of causes in futile attempt to generate standardized categories of causation. Analysts who assign causation can pick "one from column A" or "two from column B" confident of the conventional wisdom that one size cause fits all facts. The resulting data assures us that the principal "cause" of general aviation accidents is "Pilot failed to obtain or maintain flying speed". The NTSB has yet to discover that its acclaimed principal cause factor is not a "cause" at all; it is a description of what happened.
A corollary to vague specifications of causation is ineffectual preventive action. Recommenda-tions for mitigation or prevention have had little effect in forestalling the seeming inevitability of prevalent accident mechanisms. Preventing recurrence requires specific identification of what went wrong, and precise remedies to change behaviors which enabled the progress of the accident process, or failed to recognize and arrest it.
Assigning causes is passive. It is little more than assigning responsibility and accountability, or "blame". Preventing recurrence requires action. It necessitates identifying specific dysfunctionalities, tracing their origins and changing the behavior which led both to and from them.
(If you do not believe that investigators assign blame, I invite your reference to Gerard Bruggink's paper "To Kill a Myth" presented at the 1987 ISASI Seminar. (Br:87) He argues that "By emphasizing `Who Caused the Accident?' rather than `What Might Have Prevented It?', investigation authorities engage in weighing causes and, therefore, weighing blame. Causal summaries identify the individuals and organizations that seem to be most at fault, balancing between probable cause and contributing factors.")
The two objectives which the NTSB attempts to achieve -- determining cause(s) and preventing recurrence -- are countervalent; that is, they are so fundamentally inconsistent that increasing concentration on one diminishes the worth of the other. So long as we cannot even define what "causes" are, efforts expended in their quest are squandered. Worse yet, the more vague the subsumed causal elements, the more efforts must be devoted to searching for things which have not, and cannot, be defined.
Organizational inefficiencies arise from constraints. In his theory of Constraints (Go:90), Goldratt defines the nature of a "constraint":
The Air Commerce Act of 1926 and subsequent legislation formally mandated three objectives for U.S. government aviation mishap investigative authorities. It is apparent after 60 years that the agencies' concentration on the goal of determining causation has inhibited their ability to effect the others. They have continually succeeded in identifying something called "causes", yet they have failed either to identify accidents' facts, conditions and circumstances with rigor, or to produce recommendations which have prevented recurrence of similar accidents.
The NTSB's constraint is evident: it has chosen a policy which gives precedence to determining causes over preventing recurrence. Its investigators converge on the objective of determining the all-encompassing "Cause", and neglect legitimate cause-effect relationships which determine the progress of the accident processes. Thus they overlook potential early intervention points which possess realistic probabilities for effecting prevention.
Current investigation authority performance expectations cannot be elevated until the priority of objectives conflict is resolved:
The decision must be based on objective evaluation to determine which alternative has the greater opportunity for benefiting the aviation industry and its customers, not on convenience for investi-gators or the traditional practices of investigation authorities.
The policy constraints which have arisen from the NTSB's conflicting objectives can be obviated by changing priorities. Were the first priority of the investigative authority to identify the "facts, conditions and circumstances" relating to the accidents which it investigates, the issue of causal vagueness would be eliminated. Facts, conditions and circumstances may be uncertain or ambiguous, but those problems can be overcome by additional facts, data and information. Facts, conditions and circumstances are never vague. They are tangible, measurable descriptions of what happened. Once we know what happened, we can break the scenario down into specific events and conditions which encourage applying the tests and proofs of formal logic.
Four hundred years ago Bacon recognized that simple enumeration of events was inadequate methodology with which to conduct inductive logical analyses. John Stuart Mill (1806-1873) developed his classical canons of inductive inference which encompass concepts of causation and effect. (CoCo:90) These methodologies are essential tools which enable investigators to develop a Calculus of Causation; i.e., what happened --establishing with rigor the structure of causation which was precursor to the effect:
The observation that in causal explanation not just one "probable cause", but normally many causal factors explain the occurrence of an event, and that one cannot distinguish between "more necessary" and "less necessary" factors, is often attributed to John Stuart Mill; for example,... (GeHo:97)
Mill's enduring principles have been adapted to the task of accident investigation and analysis in at least two specific applications. [(Be:97) and (GeLa:97a)] Benner calls his methodology "Multilinear Events Sequencing" ("MES"). It enables the investigator to apply sequential, cause-effect, necessity and sufficiency logic tests to develop a matrix of events leading to the undesired outcome. MES can generate patterns of "event-pairs" which enable the investigator or analyst to compare discrete patterns among several accident processes. (Be:97)
Ladkin et al call theirs "WB-Graph" (from "Why-Because"). It formalizes a methodology which enables the investigator or analyst to identify significant system states and events, express them as propositional variables, and apply counterfactual testing to build a quasi-chronological graph of causal-factor relationships among sequential sets of variables. Although the methodologies differ in their semantics and logic testing, their outcomes and their utility to investigators are substantially similar. (GeLa:97a)
Goldratt's theory of Constraints, "[w]hen effectively applied,...empower[s] the user to identify precisely and to execute the one or two focused changes that will produce the maximum system improvement with the minimum investment of time, energy, and resources --and do it right the first time, without costly trial and error." He proposes that each cause normally has more than one effect. To test the validity of the assumed Cause(Effect logic the analyst must find evidence of another expected coincident effect. [(Go:90) & (De:97)] Goldratt calls this phenomenon the "Effect-Cause-Effect" test. Dettmer restates it as follows:
Investigators can reduce their vulnerability to criticism from special-interests by aggressively applying Cause=>Effect logic, testing their hypotheses and demonstrating replicability. Conclusions based on demonstrated logical reasoning are decidedly less assailable than those which call for blind acceptance of the investigating agency's experience and reputation.
Cause=>Effect logic enables self-testing by hypothesizing counterfactual arguments; i.e.,
Hypothesis: If Cause A results in Effect B, then
Test: Remove Cause A.
If Effect B still happens, then Cause A cannot be a "cause" of Effect B.
Let's look at a few examples:
In my article titled "Are These the Same Accident?" (Ri:83) I presented the outcomes of a General Aviation accident investigation. The field investigation report includes the following statement by the investigating officer (in this case an FAA inspector):
Furthermore, from the PIC's statement as to causation:
The "Probable Cause(s)" stated in the NTSB's Brief Format for the same report are:
Application of a simple counterfactual logic test demonstrates immediately the fallacies of both "probable causes"; e.g.,
[Ludi Benner and I used this accident to demonstrate the Multilinear Events Sequencing methodology in Part 2 of (BeRi:91).]
The results of Ladkin's WB-Graph analysis of the Lufthansa A320 accident at Warsaw in December, 1993, will reassure major accident investigators that they are capable of committing similar logical errors.
Further into the logic testing process itself:
A similar WB-graph analysis of the accident involving American Airlines Flight 965 enroute to Cali, Colombia, on 20th December 1990, has been performed and is available. (GeLa:97b) One conclusion in particular should concern investigators and those employing investigation reports for the purpose of prevention:
Findings section lists only 16 of these (roughly a quarter), corresponding to 10 explicit findings.
Dettmer cites eight Categories of Legitimate Reservation which should be tested to assure that analytical logic has been verified:
Whatever hypothesis testing methodology investigating authorities choose to employ, its objec-tivity discourages the kind of special interest controversies that arose during the Cutting accident, and survive to do mischief to this day. By removing the "judgment calls" from the investigation and analysis process, robust logical assessment forces critics to demonstrate that their theories conform more plausibly with the factually-derived chronology of what happened. 
Before we decide where we want to go, we must determine accurately where we are in our progress toward fulfilling the objectives of investigations, both within government and outside it.
Several years ago I asked a senior NTSB investigation manager to identify the agency's customers. He asserted that the NTSB had no `customers'.
In that case, I continued, how are quality standards for NTSB investigations established? By the other investigators, he declared. They were the only ones competent to evaluate the work of their peers.
I tried again: What about congressional oversight? Congress was necessary to appropriate funds, he said, but legislators and their staffs were generally too ignorant to be able to criticize the NTSB's work, although they managed to interfere continually.
Times have changed. The Congress has established a new purpose for the NTSB: providing assistance to families of passengers involved in aircraft accidents -- "the families of passengers involved in aircraft accidents within the United States involving an air carrier or foreign air carrier and resulting in a major loss of life."
In my final editorial as editor of ISASI's forum I proposed, as a professional position for ISASI to take to help effect credible prevention strategies:
I was wrong. The Aviation Disaster and Family Assistance Act for the first time designated real people to whom investigation authorities were accountable, real people who:
Although currently only applicable to the NTSB, it is likely that similar initiatives will spread worldwide. If so, investigation authorities will no longer be able to ignore accountability to their customers.
In the aftermath of the ValuJet crash in Florida in 1996, William Langewiesche compiled a roster of lessons which all participants in the aviation transportation system need to learn, not least those responsible for investigating accidents and attempting to prevent their recurrence (La:98):
Investigation authorities and their investigators must be educated and trained to recognize and expose systemic unsuitabilities, unfitness and irrelevance, and recommend changes even to those regulatory dogmas that have survived unquestioned since their origins. Gerard Bruggink once averred that a principal factor in accident causation is the "...uncritical acceptance of easily verifiable assumptions." More contributory factors might be discovered were we to replace "uncritical acceptance" with more stringent verification.
It has recently become fashionable to invoke esoteric statistics to support conflicting and even contradictory predictions of future aircraft accident occurrences. Some forecasters reckon that a static accident rate will combine with increasing air carrier traffic volume to produce a major accident a week within ten years. (FAA:95a, FAA:95b, FSF:96) Another performed statistical jiggery-pokery to conclude that larger aircraft will actually decrease international air traffic density. (Br:98) Nonetheless, the Flight Safety Foundation's analysis should be a challenge not only to the regulatory authority to which it is addressed, but to investigating authorities as well:
Current investigation products do not support these objectives. We have no objective measure of whether recommended "fixes" actually work. It is possible --even probable --that a substantial proportion of current "safety" regulations, policies, and operational procedures have no effect on achieving prevention or, worse yet, are actually inimical to safety.
Investigation work products should be the principal sources for identifying the fundamental factors upon which to build aviation system safety improvements. The usefulness of those work products depends on investigations incorporating rigorous methodologies which establish, test and verify a Calculus of Causation.
It is not enough for investigating authorities merely to generate arbitrary recommendations for transmittal to their regulatory counterparts. Recommendations which arise from fallacious "causes" cannot contribute to prevention. Those derived from the findings of competent investigations must be tracked after implementation to verify their quantitative efficacy. Authoritative assignment of bureaucratic responsibilities can bring accountability to the process of accident prevention.
It's time we got moving. We have already fallen far behind time's innovation curve.
The inspiration for this paper arose from the frequently contentious (but always polite) discussions which originated from Ludi Benner's Investigation Process Research References Library [at http://www.iprr.org] and subsequently expanded into a forum within which persons with widely disparate investigation expertise were encouraged to shed the constraints of tradition and indulge their imaginations in brainstorming new approaches to both investigation and prevention. I acknowledge the contributions of the Investigation Process Research References Library IRRegulars, from whom many of the ideas in the paper arose, and who motivated my search for some other tool than the ubiquitous hammer:
Michael Allocco; FAA Office of System Safety
Ludwig Benner, Jr.; Investigation Researcher & Former Chief, NTSB Hazardous Materials Division (Retired)
Hughes Chicoine; Certified Fire & Explosion Investigator (including arson), Montreal, PQ, Canada
Steve Corrie, FAA Office of System Safety & Former NTSB Major Accident Investigator
Professor Peter B. Ladkin; University of Bielefeld, Germany
Professor Nancy Leveson; University of Washington
Dr. C. O. Miller; Attorney, Engineer and Former Director, NTSB Bureau of Aviation (Retired)
Jim Stewart; Director-General, System Safety, Transport Canada (Retired)
Frank Taylor; Director, Cranfield University Aviation Safety Centre, U.K.
Professor William Waldock; Embry-Riddle Aeronautical University - Prescott
Richard H. Wood; Former Director, U.S.C. Aviation Safety Programs & Colonel, U.S. Air Force (Retired)
Dmitri V. Zotov; Lecturer in Accident Investigation, Massey University, N.Z.
. Public Law 69-254, 44 Stat. 568
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