Public safety investigations - A new evolutionary step in safety enhancement?

Over the past years, natural catastrophes have disrupted society: the tsunami in December 2004, hurricane Katrina in the Gulf of Mexico, the earthquakes in Pakistan in 2005, causing massive material destruction and human suffering. In addition, technological accidents in transport, energy and process industry undermine the public faith in risk management, while the uncontrolled spreading of diseases and viruses put high demands on medical and emergency responses and public governance decision making. The use of experiences and lessons learned from such major events is considered a valuable tool in understanding causal mechanisms and in taking appropriate measures to prevent recurrence, reduction of the consequences and restoring public faith in governance and decision making. Started in the transportation industry in the early sixties of the previous century, the phenomenon of independent public safety investigations has now been recognized as a valuable tool for safety enhancement in other industrial sectors and areas of public governance. At an international level, the EU has issued several Guidelines for their mandatory application in high-tech sectors, putting demands on the Member States to install independent governmental agencies, to harmonize concepts and investigation procedures and to feed back their findings and recommendations in EU policy making. Apart from their substantive contribution to improving knowledge about causal phenomena and accident prevention, safety investigations have been advocated as high potential tools in restoring public faith after a major event and in arbitration in societal dissensus about risk acceptability and risk perception. Safety investigations focus on enhancing the systems safety performance in contrast to accident investigations, which have their focus on preventing recurrence of accidents and incidents. Conducting safety investigations have been characterized as a Citizens' Right and Society's Duty. Such a recognition however, also sets a series of challenges for a wider application of this investigation tool outside its original technical domain, expanding the concept to all phases of the accident sequence, before, during and after the event, and to higher levels of the socio-technical systems in which the events are embedded and risk debates require expertise in supporting risk ion making. This contribution is primarily based on observations of trends and patterns as they emerge in society, and by the lack of scientific literature, assessed by expert judgment. It describes and analyses several trends and types of investigations that have developed over the past decade, focusing on their strengths and weaknesses, dilemmas, potential for prevention and ability to change systems safety characteristics. It identifies critical areas of attention for further development focusing on substantive issues as well as specific sectorial and national constraints in their implementation. (Less)