In accident reports

One of the most common mistakes in accident analyses is the use of hindsight bias. Words such as could have or should have in accident reports are judgments that are almost always the result of such bias [50]. It is not the role of the accident analyst to render judgment in terms of what people did or did not do (although that needs to be recorded) but to understand why they acted the way they did. 

The biggest problem with hindsight bias in accident reports is not that it is unfair (which it usually is), but that an opportunity to learn from the accident and prevent future occurrences is lost. It is always possible to identify a better decision in retrospect—or there would not have been a loss or near miss—but it may have been difficult or impossible to identify that the decision was flawed at the time it had to be made. To improve safety and to reduce errors, we need to understand why... 

An important question is what responsibilities should be assigned to the control structure components. The hst below is derived from the author s experience on a large number and variety of projects. Many also appear in accident report recommendations, particularly those generated using CAST. 

Conflicting goals between production and maintenance backlog prioritized maintenance or changes not performed at due date in 8 cases. (In accident report 3, 9, 11, 13, 15, 17, 22, 25). 

Poor learning from incidents and poor systematic evaluation of repeated incidents in 8 cases. (In accident report 1,3,5,9,10,20,27,28.) In general poor training in 6 cases (In report 14,23,24,26,27,28). 

Miscommunication between different actors during critical operations in 7 cases. (In accident report 4, 6, 7, 12, 16, 19,21k... 

This paper does not intend to discuss the merits and shortcomings of these two different views. However, it is irrelevant whether (linear) epidemiological views are accepted, or a systemic approach is preferred the identification of unsafe acts and preconditions of unsafe acts in accident reports alone, without discussing how the surrounding conditions are caused and influenced (either static or dynamic) by different hierarchical actors, and how this in turn may influence individual performance, does not provide much insight in the development of the accident. It also does not help in the accident prevention. 

IN CASE OF ACCIDENT, COMPLETE INFORMATION BELOW BEFORE YOU TURN IN ACCIDENT REPORT KIT TO YOUR SUPERVISOR. 

Comparisons between countries. Where appropriate data are available, comparisons can be made between accidents in one coxmtry and anotiier, either for the country as a whole, or by industry or service sector. However, there are major variations in accident reporting procedures between countries so that comparisons of this type should be made with great care. 

Johnson, C.W., Wright, PC. and McCarthy, J.C. (1995), Using a Formal Language to Support Natural Language in Accident Reports, Ergonomics, 38,1264-1282. 

People have their own unique experience of specific tasks and the hazards which those tasks present. The experiences of accident victims, frequently recorded in accident reports, are an important source of information. Feedback from accidents is crucial in order to prevent repetition of them. 

List five pieces of necessary information in accident reporting. 

This framework enables us to identify Six Critical Moments of Rhetorical Transformation in large regulatory industries. At these moments, writers must extract information that is presented in one rhetorical modality (oral testimony, for example) and literally change the form so that the information can be re-represented for a different audience (1) when oral testimony and embodied experience are captured in writing (2) when the information in accident reports is re-represented in statistical records (3) when statistical accounts are re-represented as arguments for particular policies (4) when policies and standards are transformed into procedures (5) when written procedures are transformed into training and (6) when training is re-represented to workers at local sites. (Chapter 2 describes the cycle in detail.)... 

Statistical reports (Document C) are situated within the agency headquarters. At this level, agency personnel categorize and abstract information in accident reports and industry production records to produce statistical summaries they can use to analyze trends in the industry. Agency personnel use this data to pinpoint sites and practices that require special attention. They can then determine where to focus their efforts to reduce and manage risk. 

Chapters 4 and 5 examine two specific features of this documentation the writer s viewpoint and the representation of embodied knowledge in speech and gesture. Chapters 6-8 look at ht)w these rhetorical features affect two. specific moments of transformation—in accident reports and training. 

Writers live in a world of texts and believe in the power of texts to reconstruct or construct the material world as representations. Writers also live outside of the material sites I have described in this text, but they are called upon to (a) theorize about the ways that this world works (b) represent its successes and failures in accident reports and investigations (c) analyze and comprehend failures of language and failures of technology and (d) use their analyses to construct instructions, policies, and procedures to prevent disasters in the future. 

We recognise these different factors in many of the standard forms for use in accident reporting in Europe also. Statistics, based on the classification of accidents in accordance with these categories, usually show that a majority... 

Figure 10.7 shows the results of an analysis performed by the author of safety measures documented in accident reports at seven shipyards. There were no actions documented in more than a third of the accident reports. Instructions to take care or to use prescribed personal protection or method of work were otherwise the most common types of measures. Only very few measures were of a preventive type, e.g. changes in method of work, procedure or organisation to prevent recurrence. The results from the yards are typical for many workplaces and illustrate that only very few types of measure are actually employed in accident prevention. 

Weighted average level of feedback in accident reports from three offshore projects. 

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