Safety is monitored by various proactive and reactive methods, including the investigation of adverse accidents and incidents, which are collectively known as safety investigations. In this study we demonstrate how accident and incident investigation reports can be useful to identify implicit safety views and accident investigation approaches. An analysis framework was developed based on contemporary safety literature. The framework incorporates aspects such as hindsight bias, judgemental approach, proximal or distal focus, and the application of systemic versus sequential accident causation models. The framework was piloted through the analysis of sixteen (16) accident investigation reports published by a Nuclear Power Plant (NPP). The comments of independent researchers lead to framework refinements that increased the inter-rater reliability substantially. The initial results were validated through interviews with the staff of the NPP. Afterwards, the framework was applied to 52 air accident reports published by the Dutch Safety Board (DSB) from 1999 to 2013. Frequency calculations revealed the extent of new safety thinking embracement from the DSB, and Fisher’s Exact Test showed that none of the modern safety aspects has changed over time. The framework can be used to analyse accident investigation reports published by various organisations as means to identify implicit safety views and evolution of accident investigation practices over time. Further research will explore the reasons for potential gaps between theory and practice and contribute to minimizing such distance. Safety is monitored by various proactive and reactive methods, including the investigation of adverse accidents and incidents, which are collectively known as safety investigations. In this study we demonstrate how accident and incident investigation reports can be useful to identify implicit safety views and accident investigation approaches. An analysis framework was developed based on contemporary safety literature. The framework incorporates aspects such as hindsight bias, judgemental approach, proximal or distal focus, and the application of systemic versus sequential accident causation models. The framework was piloted through the analysis of sixteen (16) accident investigation reports published by a Nuclear Power Plant (NPP). The comments of independent researchers lead to framework refinements that increased the inter-rater reliability substantially. The initial results were validated through interviews with the staff of the NPP. Afterwards, the framework was applied to 52 air accident reports published by the Dutch Safety Board (DSB) from 1999 to 2013. Frequency calculations revealed the extent of new safety thinking embracement from the DSB, and Fisher’s Exact Test showed that none of the modern safety aspects has changed over time. The framework can be used to analyse accident investigation reports published by various organisations as means to identify implicit safety views and evolution of accident investigation practices over time. Further research will explore the reasons for potential gaps between theory and practice and contribute to minimizing such distance.
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The paper presents a framework that through structured analysis of accident reports explores the differences between practice and academic literature as well amongst organizations regarding their views on human error. The framework is based on the hypothesis that the wording of accident reports reflects the safety thinking and models that have been applied during the investigation, and includes 10 aspects identified in the state-of-the-art literature. The framework was applied to 52 air accident reports published by the Dutch Safety Board (DSB) and 45 ones issued by the Australian Transport Safety Bureau (ATSB) from 1999 to 2014. Frequency analysis and statistical tests showed that the presence of the aspects in the accident reports varied from 32.6% to 81.7%, and revealed differences between the ATSB and the DSB approaches to human error. However, in overall safety thinking have not changed over time, thus, suggesting that academic propositions might have not yet affected practice dramatically.
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Modern safety thinking and models focus more on systemic factors rather than simple cause-effect attributions of unfavourable events on the behaviour of individual system actors. This study concludes previous research during which we had traced practices of new safety thinking practices (NSTPs) in aviation investigation reports by using an analysis framework that includes nine relevant approaches and three safety model types mentioned in the literature. In this paper, we present the application of the framework to 277 aviation reports which were published between 1999 and 2016 and were randomly selected from the online repositories of five aviation authorities. The results suggested that all NSTPs were traceable across the sample, thus followed by investigators, but at different extents. We also observed a very low degree of using systemic accident models. Statistical tests revealed differences amongst the five investigation authorities in half of the analysis framework items and no significant variation of frequencies over time apart from the Safety-II aspect. Although the findings of this study cannot be generalised due to the non-representative sample used, it can be assumed that the so-called new safety thinking has been already attempted since decades and that recent efforts to communicate and foster the corresponding aspects through research and educational means have not yet yielded the expected impact. The framework used in this study can be applied to any industry sector by using larger samples as a means to investigate attitudes of investigators towards safety thinking practices and respective reasons regardless of any labelling of the former as “old” and “new”. Although NSTPs are in the direction of enabling fairer and more in-depth analyses, when considering the inevitable constraints of investigations, it is more important to understand the perceived strengths and weaknesses of each approach from the viewpoint of practitioners rather than demonstrating a judgmental approach in favour or not of any investigation practice.
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