| 1. |
- Lundberg, Jonas, et al.
(author)
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Strategies for dealing with resistance to recommendations from accident investigations
- 2012
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In: Accident Analysis and Prevention. - : Elsevier. - 0001-4575 .- 1879-2057. ; 45, s. 455-467
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Journal article (peer-reviewed)abstract
- Accident investigation reports usually lead to a set of recommendations for change. These recommendations are, however, sometimes resisted for reasons such as various aspects of ethics and power. When accident investigators are aware of this, they use several strategies to overcome the resistance. This paper describes strategies for dealing with four different types of resistance to change. The strategies were derived from qualitative analysis of 25 interviews with Swedish accident investigators from seven application domains. The main contribution of the paper is a better understanding of effective strategies for achieving change associated with accident investigation.
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| 2. |
- Lundberg, Jonas, et al.
(author)
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What you find is not always what you fix : How other aspects than causes of accidents decide recommendations for remedial actions
- 2010
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In: Accident Analysis and Prevention. - : Elsevier BV. - 0001-4575 .- 1879-2057. ; 42:6, s. 2132-2139
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Journal article (peer-reviewed)abstract
- In accident investigation, the ideal is often to follow the principle "what-you-find-is-what-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.
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| 3. |
- Lundberg, Jonas, et al.
(author)
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What-You-Look-For-Is-What-You-Find : The consequences of underlying accident models in eight accident investigation manuals
- 2009
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In: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 47:10, s. 1297-1311
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Journal article (peer-reviewed)abstract
- Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of what we currently know - or assume about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. in this paper we examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, we focus on accident models and in particular the assumptions about how different factors interact to cause - or prevent - accidents, i.e., the accident "mechanisms". Secondly, we focus on the scope in the sense of the factors (or factor domains) that are considered in the models - for instance (hu)man, technology, and organization (MTO). Thirdly, we focus on the system of investigation or the activities that together constitute an accident investigation project/process. We found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the 'What-You-Look-For-Is-What-You-Find' or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called 'What-You-Find-Is-What-You-Fix' or WYFIWYF principle.
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| 4. |
- Rankin, Amy, et al.
(author)
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Resilience in everyday operations : A framework for analyzing adaptations in high-risk work
- 2014
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In: Journal of Cognitive Engineering and Decision Making. - : SAGE Publications. - 1555-3434 .- 2169-5032. ; 8:1, s. 78-97
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Journal article (peer-reviewed)abstract
- Managing complexity and uncertainty in high-risk sociotechnical systems requires people to continuously adapt. Designing resilient systems that support adaptive behavior requires a deepened understanding of the context in which adaptations take place, of conditions and enablers to implement these adaptations, and of their effects on the overall system. Also, it requires a focus on how people actually perform, not how they are presumed to perform according to textbook situations. In this paper, a framework to analyze adaptive behavior in everyday situations in which systems are working near the margins of safety is presented. Further, the variety space diagram has been developed as a means to illustrate how system variability, disturbances, and constraints affect work performance. The examples that underlie the framework and the diagram are derived from nine focus groups with representatives working with safety-related issues in different work domains, including health care, nuclear power, transportation, and emergency services.
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| 5. |
- Rollenhagen, Carl, et al.
(author)
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The context and habits of accident investigation practices : A study of 108 Swedish investigators
- 2010
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In: Safety Science. - : Elsevier BV. - 0925-7535 .- 1879-1042. ; 48:7, s. 859-867
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Journal article (peer-reviewed)abstract
- The context and habits of accident investigation practices were explored by means of questionnaire data obtained from accident investigators in the healthcare, transportation, nuclear and rescue sectors in Sweden. Issues explored included; resources, training, time spent in different phases of an investigation, methods and procedures, beliefs about causes to accidents, communication issues, etc. Examples of findings were: differences in the extent to which the 'human factor' was perceived as a dominant cause to accidents; manning resources to support investigations were perceived as rather scarce; underutilization of data from safety related processes such as risk analysis and auditing data; the phase of suggesting remedial actions (recommendations) were comparatively brief and generally not well supported. A majority of the investigators thought that the investigations were free from pressures to follow a specific direction; the investigators also thought that performing an investigation in itself (regardless of the specific results) had positive influences on safety. A majority of the investigators thought that upper management had a relatively strong influence on safety in the organizations. The results are discussed in terms of suggestions for strategies to strengthen investigation practices - particularly those conducted as part-time work in organizations.
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