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Launched Aug 26 1996.
|Improving Accident Reports
(click on Johnson to see paper)
Accident reports are intended to explain the causes of human error and system failure. They are based upon the evidence of many different teams of experts and are, typically, the result of a lengthy investigation process. They are important documents because they ultimately help to shape legislation. They also guide the intervention of regulatory authorities who must reduce the impact and frequency of human 'error' in the workplace. There are, however, a number of problems with current practice. In particular, accident reports often contain fallacious arguments .Lines of analysis may ignore contradictory evidence and alternative hypotheses. This paper, therefore, presents seven guidelines or heurisitics that are intended to improve the quality of argument in accident reports. Such principles are of little benefit unless analysts have tools that help them to meet these requirements. This paper, therefore, goes on to show how graphical extensions to Knuth's 'literate programming' can be used to avoid the weaknesses of existing accident reports.
Keywords: accident analysis; argument; logic; reasoning; human error; system failure.