Abstract
For a long time, the aim of safety science has been to further improve safety through more extensive analysis methods (address more factors, with increasingly complex causality models). However, recent research has uncovered how the application of even very advanced methods are subjects to the same pressures of reality of work, as other work tasks, and may therefore also have ‘incidents’, where all issues are not examined with equal thoroughness, and not implemented with the same enthusiasm. Some of these performance shaping factors may be systemic, affecting many investigations, resulting in investigation “blind spots”. This can facilitate the build-up of latent risk conditions in otherwise ultra-safe organizations, resulting in what is in the literature called a man-made disaster (or, less dramatically, a man-made incident). In this paper, we present an approach to uncovering “blind spots” in investigation processes, describing how it was applied at an Air Navigation Service provider.
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References
Turner, B.A.: Man-Made Disasters. Wykeham, London (1978)
Hollnagel, E.: FRAM: The Functional Resonance Analysis Method - Modelling Complex Socio-technical Systems. Ashgate, Farnham (2012)
Leveson, N.: A new accident model for engineering safer systems. Saf. Sci. 42, 237–270 (2004)
Albery, S., Borys, D., Tepe, S.: Advantages for risk assessment: evaluating learnings from question sets inspired by the FRAM and the risk matrix in a manufacturing environment. Saf. Sci. 89, 180–189 (2016)
Yang, Q., Tian, J., Zhao, T.: Safety is an emergent property: Illustrating functional resonance in Air Traffic Management with formal verification. Saf. Sci. 93, 162–177 (2017)
Dodshon, P., Hassall, M.E.: Practitioners’ perspectives on incident investigations. Saf. Sci. 93, 187–198 (2017)
Lundberg, J., Rollenhagen, C., Hollnagel, E.: What you find is not always what you fix–how other aspects than causes of accidents decide recommendations for remedial actions. Accid. Anal. Prev. 42, 2132–2139 (2010)
Lundberg, J., Rankin, A., Rollenhagen, C., Hollnagel, E.: Strategies for dealing with resistance to recommendations from accident investigations. Accid. Anal. Prev. 45, 455–467 (2012)
Wrigstad, J., Bergström, J., Gustafson, P.: Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. BMJ Open 4, e005326 (2014)
Salmon, P.M., Goode, N., Taylor, N., Lenné, M.G., Dallat, C.E., Finch, C.F.: Rasmussen’s legacy in the great outdoors: A new incident reporting and learning system for led outdoor activities. Appl. Ergonomics 59, 637–648 (2017)
Lundberg, J., Rollenhagen, C., Hollnagel, E.: What-You-Look-For-Is-What-You-Find - The consequences of underlying accident models in eight accident investigation manuals. Saf. Sci. 47, 1297–1311 (2009)
Reason, J.: Managing the Risks of Organizational Accidents. Ashgate, Burlington (1997)
Licu, T., Cioran, F., Hayward, B., Lowe, A.: EUROCONTROL—Systemic Occurrence Analysis Methodology (SOAM)—a “Reason”-based organisational methodology for analysing incidents and accidents. Reliab. Eng. Syst. Saf. 92, 1162–1169 (2007)
Rankin, A., Lundberg, J., Woltjer, R., Rollenhagen, C., Hollnagel, E.: Resilience in everyday operations: a framework for analyzing adaptations in high-risk work. J. Cogn. Eng. Decis. Making 8, 78–97 (2014)
Heinrich, H.W.: The Accident Sequence. Safety Talks, pp. 1–5 (1934)
Heinrich, H.W.: Industrial Accident Prevention: A Scientific Approach. McGraw-Hill, New York (1931)
Heinrich, H.W.: The foundation of a major injury. Travelers Stand. 17, 1–10 (1929)
Heinrich, H.W.: The origin of accidents. Travelers Stand. 16, 121–137 (1928)
Rankin, A., Lundberg, J., Woltjer, R.: A framework for learning from adaptive performance. In: Nemeth, C., Hollnage, E. (eds.) Resilience Engineering in Practice, Volume 2 - Becoming Resilient, pp. 79–95. Ashgate, Farnham, UK (2014)
Korolija, N., Lundberg, J.: Speaking of human factors: Emergent meanings in interviews with professional accident investigators. Saf. Sci. 48, 157–165 (2010)
Rollenhagen, C., Westerlund, J., Lundberg, J., Hollnagel, E.: The context and habits of accident investigation practices: a study of 108 Swedish investigators. Saf. Sci. 48, 859–867 (2010)
Filipsson, G.: Rutin för utredningar. LFV company internal process description of investigation within LFV, LFV (2016)
Acknowledgements
This research was funded by the Swedish Transport Administration and LFV. The support from the LFV Safety Department made this project a success. At last a sincere thanks to the investigators at LFV for sharing insights and experiences on top of their regular tasks.
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Lundberg, J., Josefsson, B. (2019). A Pragmatic Approach to Uncover Blind Spots in Accident Investigation in Ultra-safe Organizations - A Case Study from Air Traffic Management. In: Boring, R. (eds) Advances in Human Error, Reliability, Resilience, and Performance. AHFE 2018. Advances in Intelligent Systems and Computing, vol 778. Springer, Cham. https://doi.org/10.1007/978-3-319-94391-6_19
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DOI: https://doi.org/10.1007/978-3-319-94391-6_19
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