What you find is not always what you fix-How other aspects than causes of accidents decide recommendations for remedial actions

摘要

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.