The context and habits of accident investigation practices: A study of 108 Swedish investigators
Introduction
Accident and incident investigations are vital ingredients of safety management. The academic interest in accident investigations has traditionally focused on results from specific investigations, typically major accidents (Balasubramanian and Louvar, 2002, Drogaris, 1993, Le Coze, 2008), and on various methods and techniques for experience feedback including accident investigation (Benner, 1975, Dien et al., 2004, Johnson, 2002, Johnson and Holloway, 2003, Kjellén, 2000, Katsakiori et al., 2009, Sklet, 2004). Little attention is normally devoted to the organizational context in which an investigation takes place. Consequently, we have few answers to questions such as: how much time is spent on the different phases of an investigation (planning, analysis, etc.); how much and what type of training support investigator practices; which professional networks (if any) support investigators practices? Answers to questions such as these may be useful to make the process of accident investigation more efficient, reliable, and precise.
Another important set of questions concern investigators’ personal beliefs about accident causation and how these might affect investigation practices. For example, how are general concepts such as ‘the human factor’ and ‘safety culture’ perceived and applied in investigation practices, and how do accident investigators think about ‘causes’ to events in those branches in which they operate?
The present study (conducted in 2008) aimed at providing answers to questions such as those above with the help of a sample of Swedish accident investigators who work in different sectors (health care, nuclear, rescue service, etc.). The study is part of an ongoing research program that aims to shed light on different factors that affect accident analysis and design of remedial actions. The results will be used to support accident investigator practices by means of training, seminars, etc.
A questionnaire was used comprising both open questions to be answered in free text and evaluation scales were subjects had to rate questions about accident investigation practices. Data from 108 accident investigators from various branches are included in this study. At present, our research has been mainly descriptive and hypothesis generating. The results and statistics presented below should be interpreted with care since the sample is limited. However, we feel that some of the observations are interesting enough to be presented to a wider audience, in the hope that the results can serve as input and inspiration for further and more extensive research.
Section snippets
The questionnaire
A questionnaire was developed focusing on the procedures, context, beliefs, etc., that are associated with accident investigation practices. The questions were partly based on a tentative generic model about different phases in accident investigation, used in a previous review of mainly Swedish, accident manuals (Lundberg et al., 2009). The present questionnaire included the following themes:
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Investigators characteristics and background: age, gender, affiliation, role in organization, percentage
Efforts and resources
Table 3 shows the responses to the question about how many investigators normally participated in an investigation, while Table 4 shows the average duration of an investigation.
Among those who performed an investigation themselves, the transportation and rescue samples dominated with 44%, respective 34%. In the nuclear group, there was always more than one investigator and the same response was obtained for the patient safety sample.
Table 4 shows that the nuclear sector in average spent most
Discussion
To our knowledge, data of the type presented here have not been available to any greater extent before. Roed-Larsen et al. (2004) has presented some data that addressed partly similar issues. The responses given in that survey were, however, not seen as representative of the population but rather regarded as ‘a kind of snapshot’ (the questionnaire was distributed to 150 institutions/organizations and response rate was about 30%). The findings obtained in the present study should also be
Acknowledgement
This research was sponsored by the Swedish Civil Contingencies Agency, through the project “Assumptions about accidents and their consequences for investigation and design of remedial actions.”
References (17)
- et al.
Organisational accidents investigation methodology and lessons learned
Journal of Hazardous Materials
(2004) Learning from major accidents involving dangerous substances
Safety Science
(1993)- et al.
Measuring safety climate: identifying the common features
Safety Science
(2000) The nature of safety culture: a review of theory and research
Safety Science
(2000)Software tools to support incident reporting in safety-critical systems
Safety Science
(2002)- et al.
A survey of logic formalisms to support mishap analysis
Reliability Engineering and System Safety
(2003) - et al.
Towards and evaluation of accident investigation methods in terms of their alignment with accident causation models
Safety Science
(2009) Disasters and organisations: from lessons learnt to theorising
Safety Science
(2008)
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