Tuesday, January 22, 2013

New perspective for accident investigations

This describes how I became convinced that accident investigations should adapt to end users' needs rather than forcing users to adapt to investigators practices, as is now the case.

Since 1971, I have devoted considerable time and energies inquiring into problems with accident investigation concepts, principles and practices, their sources and possible resolution, with modest successes that have been published. Since late 2006, I have been engaged in examining accident investigations have limited success, as demonstrated by continuing streams of accidents. That involved an examination of lessons learned practices flowing from accident investigation work products. Impressed by Werner and Perry's findings about why investigation lessons learned data were not used much by end users, I - fortuitously - thought it might be worth while to look at end users of investigation outputs, what they did with those outputs and how well they satisfied end users' needs. That led to a series of papers and presentations and tutorials, dealing with the relationship between investigation practices and their role lessons learning systems. This resulted in a series of papers and presentation, discussing relevant problems, challenges and opportunitiess. As the thinking in support of the papers evolved, new insights kept popping up. About a year ago, I pulled all the papers on this topic together and posted them on my pro bono web site at http://www.iprr.org/ research/llprojcontents.html, along with a list of the new insights associated with each work.

While recently viewing the list of insights in connection with another paper on lessons learning system design strategies I am working on, one of those "aha moments" occurred to me. It dawned on me that all the substantive changes to investigation processes that were emerging flowed from a significant shift in my view about whom the research should serve. I had been looking through the wrong end of the microscope. I was looking through the end that focused on investigators concepts, principles and practices, rather than on satisfying the end users' needs. I realized my previous research effort was aimed at changes that would help investigators improve their investigations within the existing causation models, with their causal determination and recommendation framework. Adding users' needs to my inquiries led to my gaining new appreciation for their need for actionable behavioral information which they could introduce into their activities with minimal effort and intervening steps, so I tried to push investigation changes in that direction. My findings led to my challenging the causal determination/safety recommendation investigation paradigm for present investigation practices and how they supported - or rather didn't support - a timely, effective and efficient lessons learning system that produced what all potential end users could and would implement.

Without realizing it, my findings had shifted my initial research perspective, from serving the investigation community to serving the end user community, with some startling consequences, the most significant of which is a clear need to change current accident investigation causation and recommendation framework to one serving end users' needs with timely, accessible and readily assimilable behavioral information.

If improved lessons learning from accidents is to be achieved, I am convinced that end users' wanting to reduce risks using investigation outputs have to stop compromising their needs by tolerating what investigators now provide them, and demand timely actionable behavioral information from investigations.

LB 11/13/10