Systems approach, accident investigation

The book is divided into three sections.The first part explains why a new approach is needed, including the limitations of traditional accident models, the goals for a new model, and the fundamental ideas in system theory upon which the new model is based. The second part presents the new, extended causality model. Ihe final part shows how the new model can be used to create new techniques for system safety engineering, including accident investigation and analysis, hazard analysis, design for safety, operations, and management. 

In contrast, the Department of Energy s MORT-based approach provides excellent accident investigation, audit, and appraisal tools oriented to ongoing operations. Despite emphasis on the importance of the upstream process, however, system safety programs based on MORT tend to lack the early, detailed, systematic hazard identification and analysis efforts that are characteristic of MIL-STD-882B programs. 

The real tragedy is our immutable belief in nonsense causation factors, such as lack of common sense and carelessness. In every failed woik system, the individual makes up onfy one component of the reason for failure. A more constructive mindset could be to always view causation as failure in a system. And a system failure will alw s result through human error in combination with other factors, never through the lone fault of the individual. Consequently, all accident investigation results must identify the role of the environment, the machinery, the materials and the procedures as other causation factors when, and if, human error is identified as a reason for the failure. This approach would largely ignore the adversarial ramifications of accident reporting in favour of a more productive outcome focused solefy on prevention of system failure in the future. 

The concepts of the safe system approach and the vision of zero accidents are becoming increasingly accepted by researchers, road safety practitioners and stakeholders internationally, and, within these concepts, the challenge to combine road safety with efficient traffic operations and capacity is investigated and promoted to decision makers. 

Blaming an individual or group of individuals for an injury-producing incident is not consistent with a systems approach to safety. Instead, an injury or near hit provides an opportunity to gather facts from all aspects of the system that could have contributed to the incident. However, most evaluations of near hits or injuries are incomplete, and are much less informative than they could be. Part of the problem here is the very term we use to describe the process—accident investigation. 

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