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Launched Aug 26 1996.
Model posted initially on 2 Jan 98
This model flow charts the general human decision process elements involved in accidents. Accidents are aborted when the decision maker or object redirects the process to the no-accident outcome. The model was developed by consolidating observations during interviews with accident investigation witnesses. Guidance for applying the model in investigations follows the model.
Source: FOUR ACCIDENT INVESTIGATION GAMES, Appendix V-F, Lufred Industries (now Ludwig Benner & Associates) Oakton, VA 1982
This Model describes the general decision making process faced by people while interactions are occurring among people, objects and energies during any kind of process. The model helps investigators discover and define changes, signals they emit; their detection, communication, and diagnosis; decisions required during the process, and the outcomes of those decisions.
By investigating effects of then current policy, supervision, training, design, procedures, supervisory acquiescence, and other programmer* input sources related to each of these elements, investigators can link specific prior actions or "human factors" to each element.
This tracking of each decision process element enables investigators to define specific relationships among actions as problems or needs. It then enables investigators to pinpoint the places to look for concrete actions (behaviors) that will change future performance, rather than describing problems and needs in subjective, ambiguous, abstract or orther unverifiable "human factors" terms such as errors, failures, causes, malfunctions, vigilance, attention, wrong, unsafe, skill errors, latent failures, active failures, etc.
To apply this Model during investigations or interviews, identify people who appear to have had a role in the incident process. Then begin to look for changes in the process or its environment that would have created an original need for action by some person (or object) to keep the process progressing toward its intended outcome. Then follow the same procedure for subsequent changes until the incident is understood and explained.
After working with this model, investigators are in a much better position to describe and explain what happened when a so-called "human error" or"failure" is alleged. You will also be in a better position to identify concrete actions to improve future performance of that and similar systems.
* "Programmers" refers to any person whose attitudes, expressions, words, or behaviours "programmed" (or influenced) others to behave in a predetermined way, or led them to perceive that a behavior was desired, acceptable or preferred by the programmer.
Contact: Ludwig Benner at this web site.