Monday, June 28, 2010

A substitute for "causes" in accident investigations

A source of continuing confusion, debate and complaints among investigators is the the determination of "cause" in its various forms as a central investigation output. A recent presentation to the International Society of Air Safety Investigators (ISASI forum April-June 2010, p5) raises the question "The Accident Cause Statement-Is It Beyond Its Time?" It is the latest in a long series of papers that challenge cause statements in investigation reports, mine among them.

One of the shortcomings of previous challenges has been the lack of an alternative to replace the cause statements. If not cause, then what? In a 2007 paper presented to the European Safety and Reliability Data Association, I offered the first glimmer of a substitute, commenting as an aside about an example of an alternative lessons learning system design that it made cause determination moot. It wasn't until later work that I recognized the full significance of that aside.

That recognition came to fruition as I was preparing a presentation for the 16th HPRCT conference in Baltimore this month, dealing with the shortest data pathway from the generation of source data during an incident to the demonstrated performance improvement in an activity.

In that presentation, the first step I described was how to transform source data generated during any experience into improved performance, by using a new standardized structure for building blocks documenting that data. The second was an analysis structure for organizing, coupling and analyzing those building blocks to show dynamic interactions during the experience. The third was a structure for reporting lessons to be learned from those analyses as input-output behavior sets that could be overlaid onto existing operational behavior patterns. The presentation also included the benefits that could be realized, and a plan for incrementally implementing the changes into an existing operational improvement processes.

The key change is to shift from an accident causation model to an input-output process model as the basis for investigating the accident/incident phenomena. The process which produced the outcomes precipitating the investigation can be described verifiably and explained in terms of behavioral inputs and outputs among people, objects and energies. Those interactions are represented as behavior sets, as explained in the paper and presentation. Anyone insisting on selection of causes can do so according to whatever criteria they desire from the interacting behaviors described.

The paper and presentation are posted in the lessons learned research section of the web site, with a list noteworthy ideas introduced, abstracts and documents. They also can be downloaded directly from the web site home page.