Accident Theory and Analysis

Choose a story that enables you to show at least five of the following principles, and other relevant principles of (chapters of Norman “Design of Everyday Things”, and Dekker “Field Guide to Understanding Human Error”). To comment on these things, look them up in the Notes and readings and cross-reference to the page. There are several principles listed here, because some principles will be illustrated by some stories better than others.
• Understand the situation from the perspective of the person at the time they were acting. What choices were apparent to them and what consequences of those choices were apparent? Note the differences between their likely perception at the time and your perspective knowing how the situation turned out.
• Differentiate between hazards that were inherent to the design and hazards due to the operating condition (i.e., deviation in the maintenance of the design specification)
• Differentiate between actions that are unusual and dangerous and actions that are simply not compliant with rules. Show that you understand that typical operation involves people being required to improvise for efficient operation because rules do not cover all situations that arise, or are unrealistic in practice. Strictly following all rules to the letter is not always in business’ best interest, e.g., when union members “work to rule”, it is to disrupt the business, not help it. Show that you understand that a person may have adequate skills and lack only a licence (paper), or that a person may “have training” but forget it or fail to apply it.
• Describe how the event would be represented by the relevant choices from the following: STEP, Theory of Risk Homeostasis, Surry cascade, a domino theory; the latent hazards, if any, from the first actual deviation in the chain of events on this particular occasion.
• Was the situation tightly or loosely coupled, or in between? Complex, simple, or in between? Why do you describe it that way? And how did that affect the occurrence?
• Use page 30 figure 8 to explain error types involved in any human performance failure reported in the story.
• What lines of inquiry for investigating this accident are (or would be) inefficient and a waste of time? Show that you understand that safety resources are not infinite, and that spending excessive resources on irrelevant lines of inquiry means another hazard somewhere must wait for attention.
• Describe the difference between determining who is “responsible” or “at fault” or who “caused” the accident, or naming a “root cause” like “poor communication” and discovering a hazardous condition that could be corrected. Identify which of the qualities of good investigation describe this difference.