Prerequisites for learning from accident investigations - A cross-country comparison of national accident investigation boards

摘要

In this paper railway accident investigation reports issued by the national accident investigation boards in three Scandinavian countries during a 2-year period have been systematically studied. Content analysis of attributed causes in these reports reveals a considerable emphasis on physical processes, actor activities and equipment (the microlevel). Much less attention is paid to organisational factors (the mesolevel) and conditions related to regulators, associations and government (the macrolevel). This means that lessons will primarily be learned about aspects at the lower of these levels. Interviews show that the factors emphasised in investigation reports typically reflect the competences and experiences of the investigators, i.e. they are inclined to focus on areas of their own expertise. Since failures at the microlevel in many cases merely are symptoms of trouble at higher levels, it is argued that competence among investigators that supplements entirely technical or operational backgrounds are necessary for enabling deeper understanding of the factors leading to accidents. One possible way for achieving this is the creation of multi-modal investigation boards that provide a number of potential advantages, such as increased access to specialist competences that are shared between different sectors. Although a multi-modal approach to some degree has been adopted in all three countries, interviews reveal that these positive effects do not emerge automatically. It can therefore be concluded that multi-modal investigation boards offer a number of possible advantages, but only when these synergies are fully exploited can they provide a potential for more effective learning from accidents. (C) 2011 Elsevier Ltd. All rights reserved.