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Launched Aug 26 1996.
The following are reviews/comments/critiques about the Lekberg paper.
all there is to investigation.
A comment on: Different Approaches to Incident Investigation -
How the Analyst Makes a Difference
The root ANALYS* (standing for analys*is, analys*t, etc.) occurs 66 times in a text of approximately 3109 words.
And the words investigation / investigator occur once each, in the title and in one sentence.
The title suggests that an INVESTIGATION is conditioned by the individual APPROACH of the different ANALYSTS:
Different Approaches to Incident Investigation - How the Analyst Makes a Difference
2) in a sentence:
Accident and incident analyses will be guided by several different factors: one is the purpose of the investigation;
The single sentence in Lekberg's paper which addresses investigation says that the purpose of an investigation is one among several different factors, and that the analyses will be guided by such factor or purpose. I think that investigators are reluctant to superpose such guiding constraints on their work unless they nurture a preconceived notion of the result that will emerge.
As presented by Lekberg, analysis is not defined or qualified, but it imposes a "perspective". And the word "perspective" occurs 30 times in Lekberg's paper.
This is not an uncommon pattern because a similar twist exists in fire investigation and is sometimes (often) factored in the ignition sequence as follows:
The proponents of this approach often argue that the event should/must be investigated separately, at least in that perspective.
L Benner 1/24/98
Chicoine's comments point to confusion between investigation and analysis. The paper focuses on investigation into the ANALYSIS of REPORTS, not the investigation of accidents. That confusion is interesting. in that it demonstrates once again what mischief the allocation of accident "causes" from reports can create, regardless of the purposes of the investigation or analysis. In that respect, it seems to be similar in nature to the research by Johnson, Ladkin and others, who also analyze accident reports, rather than the investigations which produced the works being analyzed. Vaughan's research shows clearly why that indirect approach is less desirable than direct observations from original sources.
Lekberg demonstrates that analysis of reported accidents for the attribution of cause is a subjective exercise and dependent on the backgrounds of the analyst. This is a useful contribution to the debate about the utility of the entire cause concept when applied to accident reports and investigations.
The the definition of the problem (inconsistency) and the solution offered (integrated miltidisciplinary approach) while not unique, do not seem valid. Re the problem, an obvious question that was not answered was whether the inadequacy of the accident data contributed to the differences. Another question is why the AEB methodology did not produce greater consistency. Lekberg's solution suggests that Lekberg views the problem as attributable to the backgrounds of individuals charged with determining causes. A more logical conclusions seems to be the impossibility of the task, namely objectively and consistently satisfying the demand to select an accident cause or causes from accident reports.
As demonstrated by this project, it appears to me that applying a technically bankrupt concept to flawed data will lead to predictably inconsistent results, and that adding more people to the task will not improve the results..
Your comments are invited.