Lessons Learned research package
A package containing papers and presentations about mishap investigation LESSONS LEARNED research since 2006 has been added to this section. It includes 3 papers and accompanying presentations and scripts, 2 tutorial presentations, and a list of new insights produced by the research. 11/09
Koning-Peters Thesis The Investigator In Charge:Role or Profession examines Investigator-in-Charge issue involved at a national investigation agency. Thesis summary, document and comments are posted. Comments are invited (via AIPRE private forum) 5/07
US NASA has been developing software called Investigation Organizer that might be of interest to investigators. See schematic of system. 1/07
A study titled "Comparison Of Some Selected Methods For Accident Investigation" by Snore Sklet has been published in the J Hazard Mater. 2004 Jul 26;111(1-3):29-37. His paper gives a brief description of a selection of some important, recognised, and commonly used methods for investigation of accidents
A Thesis titled The Ethos of Error: Analyzing Investigations of Industrial Events by Douglas Sweeney proposes a theoretical basis for the analysis of investigations of industrial events, a methodology and a method by which investigative processes can be evaluated. 2004
A paper Investigating Investigation Methodologies (872K file) prepared for IRIA2003 Conference reports results of an investigation into the comparative effects of RCA and MES methodologies on investigation processes. Slide presentation (for Mac OS ) or Slide presentation (for Win OS), a copy of handout showing examples of comments about the investigation report, a second handout with examples of questions raised by MES matrix development, and a a third handout showing how the comments can be used for managing the investigation are also available. 2003. (Note: hurricane forced cancellation of presentation.)
See proceedings of IRIA 2003 Workshop on the investigating and reporting of incidents and accidents at Williamsburg, VA Sept 2003 on line at http://shemesh.larc.nasa.gov/iria03/iria2003proceedings.pdf (conference truncated by hurricane threat.)
Leveson proposes a new control-oriented Accident Model for Engineering Safer Systems. See the paper at http://sunnyday.mit.edu/accidents/esd.pdf
A Thesis titled "Human Factors in the Field: A Field Study of Accident
Investigation at the Transportation Safety Board of Canada" was shared by Leo Donati, and the Abstract is posted here.
How To Prang Your Aircraft In Six Different Ways (Or, for the academically inclined, Cognitive Failure Analysis of Pilot Error) This report of research describes results of an investigation into New Zealand investigations involving "pilot errors" and offers application of a model to help investigators with analyses in accident investigations. Although it is not the main focus of this site, the paper also describes application of the taxonomy to historical data, with some interesting results.
The report is posted here to stimulate discussion of the methodology and findings and how they relate to the improvement of accident investigation processes.
See Proceedings of a Workshop on the Investigation and Reporting of Incidents and Accidents (IRIA), at the University of Glasgow 27-30 July 2002 for several papers on investigation processes.
The Health and Safety Executive in the UK has sponsored investigation-related research, reports of which are available at the HSE web site.
ROOT CAUSE ANALYSIS: LITERATURE REVIEW is a contract research report produced in connection with projects performed for the British Health and Safety Executive, "to develop a root cause analysis tool from first principles." See report (pdf). See also related report by same organization.
A report of an investigation of 4 Investigation Models for the Province of Alberta WORKERS HEALTH, SAFETY AND COMPENSATION, Occupational Health and Safety Division has been posted. (1985) Download full report in pdf format (Harvey.pdf)
A Thesis describing a project "Assessment of Accident Investigation Methods for Wildland Firefighting Incidents by Case Study Method" has been prepared by Steven A Munson for the University of Montana, January 2000. The report develops selection criteria and preferred methods for investigating wildfire accidents and incidents.
The Report of $400,000 investigation research project by Rand Institute for Justice was released in December 1999 (10 months after the original delivery due date.). This is the largest and most recent governmental investigation agency investigation process research project conducted to my knowledge. Go to the press release summarizing the report's recommendations. Summary report can be downloaded in Acrobat format from http://www.rand.org/publications/MR/MR1122/MR1122.pdf>.
You can view both the original work statement and contract/MOU. at this site. Additional references will be provided here as they become available. (12/99)
Cause Compilation of Differing Perceptions of "cause" in papers published by the International Society of Air Safety Investigators, illustrates differences in perceptions among experienced investigators.(6/99)
Accident Report Utility. The Glasgow Accident Analysis Group is conducting a survey about accident reports: how they are obtained, used and the problems that arise in understanding them. The aim of this research is to try and improve the way that information about accidents is communicated. They are not trying to criticize the way in which accident reports are created or written but we are trying to look at the problems that the reader has in understanding those reports. This information can then be fed back into the writing process or be used to look at alternative forms of visualizing and structuring the information from accidents, Again, thanks for sharing your work product with me.. Contact P. Snowdon at http://www.dcs.gla.ac.uk/~snowdonp/quest.html for more information. Posted 12/98. Project concluded)
SAFETY'S HIDDEN DEFECT: ACCIDENT INVESTIGATION by Ludwig Benner, Jr. . Presents questions faced by investigators at the beginning of an investigation, and reports on observations and research findings about the investigation process during 1972-1979 period. Formatted as slides/overheads, as used in presentations and classrooms. Derived from SAE publication SAE/SP-80/461 ACCIDENT INVESTIGATIONS-A CASE FOR NEW PERCEPTIONS AND METHODOLOGIES. View presentation text. or slide presentation. Posted July 13, 1998.
DIFFERENT APPROACHES TO ACCIDENT INVESTIGATION-HOW THE ANALYST MAKES THE DIFFERENCE by Anna K. Lekberg. Study sought to answer question whether psychologists attributed the causes of accidents to the technical system, while engineers attributed them to the humans.. Read/download paper (Posted 23 Jan 98)
Report of the observed effects of methodologies employed and METHODOLOGICAL BIASES WHICH UNDERMINE ACCIDENT INVESTIGATIONS, published in The Proceedings of the International Society of Air Safety Investigators 1981 International Symposium, Sept 1981. (Posted 2 Jan 1998 by request.) Read/download paper.
EXPERIMENTAL ON-LINE INVESTIGATION RESEARCH PROJECT to try to identify the knowledge and skill requirements for different kinds of investigations, using the internet to gather inputs from experienced investigators. Project seeded with 9 types of investigations, 37 task descriptions. Go to project documents. Data inputs invited. (Posted 15 June 97, updated through 08 Nov 97)
SINTEF-Norway. This organization is working with government and industry clients on the adaptation of STEP and root cause analysis to accident investigations, and have expressed an interest in making their systematic approach to RCA a subject for professional discussion. For further information contact Dr Terge Sten at SINTEF -Norway(Posted 15 June 97)
PERCEPTIONS OF THE ACCIDENT PHENOMENON. Presents the results of an inquiry into differing perceptions of the accident phenomenon suggested in 36 references, and the exploration of the influences of these perceptions on accident investigation processes. DIFFERS FROM ACCIDENT CAUSATION MODEL approach . (1980) Read/download paper. (Posted 15 April 97)
GENERAL HUMAN DECISION PROCESS MODEL FOR INVESTIGATORS Presents model and application instructions resulting from research into decision process models that might help investigators produce better investigations in human factors area. 1982 Read model and application guidance (Posted June 17, 1997)
MODELS FOR ACCIDENT INVESTIGATION, by Michael D. Harvey, Ph.D., Alberta Workers Health Safety and Compensation, Edmonton. Alberta Canada ( April 1985)
2nd part of 2 part literature review for critically examining the various approaches to understanding accidents. (Posted 15 Feb. 97)
ACCIDENT MODELS AND INVESTIGATION METHODOLOGIES EMPLOYED BY SELECTED U S GOVERNMENT AGENCIES, by Ludwig Benner, for U S Department of Labor, Occupational Safety and Health Administration, Washington, DC ( Feb. 1983) Summary published under the title RATING ACCIDENT MODELS AND INVESTIGATION METHODOLOGIES, Journal of Safety Research, 16:3, Fall 1985 Chicago, IL Also reported in Hendrick and Benner, INVESTIGATING ACCIDENTS WITH STEP, Marcel Dekker New York-Basel, 1986.
Project initiated by OSHA to examine the foundations of its accident investigation program, and determine if it might be improved. Report examines and analyzes accident models and investigation methodologies of 21 U S Federal agencies. (Task 1) (Posted 15 Feb. 97)
Investigation of the role of perceptions of accident phenomenon on investigation practices, published in proceedings of International Seminar on Occupational Accident Research, September 5-9, 1983, Saltsjöbaden, Sweden, Vol. 1ACCIDENT MODELS: HOW UNDERLYING DIFFERENCES AFFECT WORKPLACE SAFETY, (Abstract) Related to OSHA study above.
FIRE RISKS IN THE CARLOAD AND TRUCKLOAD TRANSPORTATION OF CLASS A EXPLOSIVES. Analyzed accident reports to determine if new event set-based risk analysis method might be of value; provides insights into accident report data shortcomings and effects on recommendations. (1989). (Read/download report) Posted 15/ April 1997
Modify operation of investigation agency. Describes research-based changes in investigation process task designs and work flows implemented by a national investigation agency. (Read/download 1997 Status report) (Posted 4 Dec 96)
Project to develop a methodology and do accident case studies to demonstrate the cost effectiveness of good safety management practices (Read report) Project notice posted 2 Nov 96/ Updated 6 Mar 98.
Prev update: with results 12 Oct 97)
Recommendation Development and Evaluation - Ranking Safety Recommendation Effectiveness. Report of investigation into method for comparing relative merit of potential recommendations options before proposing them. (Read/download report)
Investigation Process Planning model . Summary display of project to develop a Readiness Tree model for developing or assessing investigation programs. (1996) (Current project - View Readiness tree)
The results of this research were published in section 8 of a new Handbook of Industrial Automation, Marcel Dekker, NY, 2000. (Now sold by Tailer and Francis CRC Press)
A General Human Decision Model for Accident Investigators is a model of how occurrences requiring actions by people turn into accidents or are aborted during risky activities. The model was developed from observations made and data acquired during investigations of over 30 accidents and incidents, from interviews with participants, investigators, and witnesses, and analyses of those data. View model and application procedures.
Accident Investigation: Safety's Hidden Defect. A research report of ongoing investigation research, formatted as the instructor's script to an A/V presentation. With musical score illustration. Read report. 1980, Rev to 1998.
- The Management Oversight and Risk Tree -MORT, SAN821-2, 1973. 1973. This is one of the first major research initiatives to define a safety system, including accident investigations.