The Investigation Process Research Resource Site
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Launched Aug 26 1996.

 

Abstracts

  1. ESReDA 33 Paper:
    Benner, L., Accident Data for the Semantic Web, ESReDA 33 Seminar, Ispra IT, November 2007
    Abstract
    This paper describes concerns about the documentation, dissemination and use of lessons learned from mishap investigations, impediments posed by current practices, and opportunities for improvement. Lessons are presently developed, documented and stored primarily in narrative form and relational databases, and disseminated in many forms and media, including the Internet. Current practices pose many impediments to maximized dissemination and use. New data concepts behind the Semantic Web, exploited elsewhere, offer potential opportunities to overcome these impediments. To exploit these opportunities, formation of a working group to develop an improved Semantic Web-friendly mishap investigation lessons learning system is proposed. An example illustrating one approach to developing alternatives to the present lessons learning system is presented.

  2. ESReDA33 Slide Presentation:
    Benner, L., Accident Data for the Semantic Web, ESReDA 33 Seminar, Ispra IT, November 2007
    Description: These slides were used to present the paper at the Ispra. Seminar.

  3. SSTS Tutorial:
    Benner, L. and Carey, W.D., Investigation Lessons Learning System Flaws and Fixes, Washington DC System Safety Training Seminar, La Plata MD, June 2008 (Slides)
    Abstract:
    The goal of this Tutorial is to stimulate participants to think about their "Lessons Learned" activities, and ways to improve their efficacy and value. The Tutorial first presents s a description of current mishap investigation lessons learned activities and prevalent practices. It then describes and explains the shortcomings and impediments to the development, documentation, dissemination and successful implementation of investigation lessons learned, resulting from current mishap investigation perceptions, processes and practices. The tutorial then presents the challenges one faces in trying to overcome those shortcomings and impediments. Opportunities available for meeting those challenges are then explored. The final segment presents an example of an alternative Lessons Learning System and its many elements. It then offers an interactive demonstration showing behavioral building blocks in mishap investigations and their role in supporting a better Lessons Learning System, with an illustrative step by step case study that produces semantic web-friendly system inputs, processing and outputs. The tutorial closes with a dialogue about the ideas presented, as time permits.

  4. ESReDA 36 Paper:
    Benner, L., Lessons Learning System Attributes: An Analysis, ESReDA 36 Seminar, Coimbra PT June 2009
    Abstract
    Recent high visibility accidents demonstrate that lessons learned processes continue to under-perform expectations. Our previous report showed inadequacies of present processes for learning, communicating and acting on lessons derived from accident investigations. Using a systems analysis approach we were able to isolate and document systems' attributes needed to enable more successful use of lessons learned. This paper documents insights gained, and a lessons learning system that incorporates essential functions needed to improve development, communication and use of lessons learned, to achieve expected system performance. Analyses of those functions from users, developers and system designers' perspectives led to twenty-six desired system attributes, and at least eight strategic system design alternatives. We found that the most urgent need is a redesign of the lessons-to-be-learned source data and lessons learned documentation produced by investigations.

  5. ESReDA 36 Slide presentation:
    Benner, L. Lessons Learning System Attributes: An Analysis, ESReDA 36 Seminar, Coimbra PT June 2009
    Description: These slides were used to present the subject paper at the Coimbra seminar.

  6. ISSC 09 Tutorial,
    Benner, L. and Carey, W.D., Lessons Learning System Analysis and Assessment, International System Safety Conference, Huntsville, AL August 4 2009 (Slides)
    Abstract
    One of the distinctive features of professional technical performance is self-appraisal and continuous improvement of an individual's professional endeavors. This tutorial's purpose is to provide useful criteria for self-appraisal and improved operation of the lessons learning systems which system safety professionals encounter in their work environments. It examines lessons learning systems, the expectations and contributions of system safety analyses and mishap investigations to those systems, indicators of a need for an analysis and appraisal, system performance impediments, and challenges constraining improvement. The examination addresses lessons learning system components, including lessons learning system paradigms, objectives, data needs, design, discovery, documentation, quality assurance, dissemination, access, assimilation and assessment of such systems. The tutorial then explores alternatives for achieving successful lessons learning system operation.

  7. ISSC 09 Tutorial Video
    Benner, L. and Carey, W.D., Lessons Learning System Analysis and Assessment, International System Safety Conference, Huntsville, AL August 4 2009 (See above - Abstract 6.)

  8. ISASI 2009 Paper:
    Benner, L. and Rimson, I.J., Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities, International Society of Air Safety Investigators 2009 Seminar, Orlando, FL, September 2009
    Abstract
    Recent high-visibility accidents demonstrate that processes for learning costly lessons that should be identified by investigations continue to under-perform expectations. The accident scenarios of the destruction of a Continental-Colgan DeHavilland Dash-8-Q400 at Buffalo, NY; and a FedEx MD-11 at Narita, Japan, a month later, reflect missed opportunities to learn the lessons from similar previous accidents or analyses by those who might have used that knowledge successfully to avoid the latest crashes. Current processes for identifying, defining, communicating and acting on lessons to be learned are inadequate to take advantage of the opportunities offered by investigated accidents. We undertook a systems analysis approach to define historical accident investigation lessons-learned processes and outputs, and isolate and document the systems' boundaries, functions and attributes. This paper documents our analysis and the insights gained. We incorporated the resulting successful functional elements into a "Lessons Learning System," that identifies a process from generation of lessons-to-be-learned source data to disseminating and applying lessons-learned to improve the learning organizations' safety performance. We analyzed those elements from the standpoints of lessons-learned users, and system developers and designers, which enabled us to define twenty-six desired system attributes and at least eight strategic system design alternatives. Immediate needs for improving the lessons learning processes are:

    • redesigning the form and substance of lessons-to-be-learned source data to improve their usefulness, and

    • redefining investigation product specifications to require that lessons learned be an explicitly documented product of investigation processes.

  9. ISASI 2009 Slide presentation:
    Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities, International Society of Air Safety Investigators 2009 Seminar, Orlando, FL, September 2009
    See Abstract at 8
    Description: Slides used to present the paper at the Orlando seminar.

  10. ISASI 2009 Script
    For Slide Presentation Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities International Society of Air Safety Investigators 2009 Seminar, Orlando, FL, September 2009
    See Abstract at 8
    Description:Script used to present slides at Orlando Seminar, Includes post-paper submission insights, and open source software contribution,

  11. HD Video of Presentation:
    Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities International Society of Air Safety Investigators 2009 Seminar, Orlando, FL, September 2009

  12. HPRCT 2010 Paper:
    Benner, L., Transforming Experience into Performance Improvement,16th Annual Human Perfirmance Root Cause Trending Conference, Baltimore MD June 21-25
    Abstract
    Undesired incidents generate original source data from which performance improvement actions are derived in organizations. This paper describes how front line incident investigators can leverage their effectiveness by initiating the shortest path between the original source data and actions that improve performance. The key is transforming original source data into building blocks with standardized form, structure and content. These building blocks support a standardized analysis structure, to develop timely validated descriptions of what happened. They also support a readily assimilable standardized lessons-to-be-learned structure to facilitate performance improvements. The paper describes a practical and efficient way to structure source data inputs, analyses and lessons-to-be-learned. The paper also addresses impacts on the creation of valid descriptions of what happened, development of lessons-to-be-learned, and application of those lessons to achieve improved performance, and suggests how introduce the structures.

  13. HPRCT 2010 Slide Presentation with notes (.pdf)Benner, L., Transforming Experience into Performance Improvement,16th Annual Human Perfirmance Root Cause Trending Conference, Baltimore MD June 21-25 2010
    Description:Slides and script used to present slides at Orlando Seminar