ACCIDENT INVESTIGATION - MISSED OPPORTUNITIES

摘要

After paying the high price of an accident, we often miss opportunities to learn from it: 1. We find only a single cause, often the final triggering event. 2. We find only immediate causes and do not look for ways of avoiding the hazards or for weaknesses in the management system. 3. We list human error as a cause without saying what sort of error though different actions are needed to prevent those due to ignorance, those due to slips or lapses of attention and those due to non-compliance. 4. We list causes we can do little about. 5. We change procedures rather than designs. 6. We do not help others to learn as much as they could from our experiences. 7. We forget the lessons learned and the accident happens again. We need better training, by describing accidents first rather than principles, as accidents grab our attention; we need discussion rather that lecturing, so that more is remembered; we need databases that can present relevant information without the user having to ask for it. Finally, we ask if legislation can produce improvements.