Accident Investigation: From Searching Direct Causes to Finding In-depth Causes – Problem of Analysis or/and of Analyst?

Abstract Current operating feedback systems in industry show some limits since, in numerous industrial companies, the numbers of events do not decrease anymore and similar events seem to recur. Our assumption is that weaknesses come mainly from analysis methodology used. After a description of analysis methodology history, we focus on interest of applying an organisational analysis of events, familiar to scholars but not yet applied in industry, and we describe its main characteristics after defining what we mean by “organisation”. Then we highlight roles of analysts who are not neutral in using event analysis method, assuming that these roles could be a block to progress of event analyses.

[1]  Michel Llory,et al.  Ce que nous apprennent les accidents industriels , 1998 .

[2]  M. Bourrier Le nucléaire à l'épreuve de l'organisation , 1999 .

[3]  C. Perrow,et al.  The President's Commission and the Normal Accident , 2019, Accident at Three Mile Island: The Human Dimensions.

[4]  D. Sills,et al.  Accident at Three Mile Island: The Human Dimensions , 1982 .

[5]  Nancy G. Leveson,et al.  A new accident model for engineering safer systems , 2004 .

[6]  C. Perin Organization at the Limit: Lessons from the Columbia Disaster , 2006 .

[7]  J. L. Coze,et al.  The 27 march 2003 Billy-Berclau accident : a technical and organisational investigation , 2005 .

[8]  Mark Kaszniak,et al.  CSB investigation of the explosions and fire at the BP texas city refinery on March 23, 2005 , 2006 .

[9]  Erik Hollnagel,et al.  Cognitive reliability and error analysis method : CREAM , 1998 .

[10]  John Kingston,et al.  INVESTIGATION TOOLS IN CONTEXT , 2006 .

[11]  Scott D. Sagan,et al.  Toward a Political Theory of Organizational Reliability , 1994 .

[12]  Diane Vaughan,et al.  SYSTEM EFFECTS: ON SLIPPERY SLOPES, REPEATING NEGATIVE PATTERNS, AND LEARNING FROM MISTAKE? , 2005 .

[13]  D. L. Simms,et al.  Normal Accidents: Living with High-Risk Technologies , 1986 .

[14]  Diane Vaughan,et al.  The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA , 1996 .

[15]  Snorre Sklet,et al.  Comparison of some selected methods for accident investigation. , 2004, Journal of hazardous materials.

[16]  Karlene H. Roberts,et al.  The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea , 1987 .

[17]  David Okrent,et al.  Man-made disasters , 1998 .

[18]  M. Crozier,et al.  L' acteur et le systeme , 1978 .

[19]  I. Svedung,et al.  Proactive Risk Management in a Dynamic Society , 2000 .

[20]  D. Vaughan The Trickle-Down Effect: Policy Decisions, Risky Work , 1997 .

[21]  Jens Rasmussen,et al.  Risk management in a dynamic society: a modelling problem , 1997 .

[22]  Andrew Hopkins,et al.  Failure to Learn: The BP Texas City Refinery Disaster , 2008 .

[23]  P Tearle Accident investigation. , 1998, Communicable disease and public health.

[24]  Babette Fahlbruch,et al.  Safety Related Interventions in Inter-Organisational Fields , 1998 .

[25]  Jean-Marie Faverge,et al.  L'analyse du travail : facteur d'économie humaine et de productivité , 1955 .

[26]  T. Laporte,et al.  Working in Practice But Not in Theory: Theoretical Challenges of “High-Reliability Organizations” , 1991 .

[27]  Michel Llory L'accident de la centrale nucléaire de Three Mile island. Vingt ans après : nouvelles perspectives pour la sécurité, nouvelles inquiétudes , 2000 .

[28]  Andrew Hopkins,et al.  Lessons from Longford: The ESSO Gas Plant Explosion , 2000 .

[29]  P. C. Cacciabue Accidents Industriels: Le Cout du Silence: (in French, title in English: Industrial Accidents: The Price, of Silence). By M. Llory, L'Harmatten, 1996 , 1997 .

[30]  Yves Dien,et al.  Organisational accidents investigation methodology and lessons learned. , 2004, Journal of hazardous materials.

[31]  C. Macrae Interrogating the unknown: risk analysis and sensemaking in airline safety oversight , 2007 .

[32]  C. Dejours,et al.  L'évaluation du Travail a l'Épreuve du Réel Critique des Fondements de l'Évaluation : Une Conférence-Débat Organisée Par le Groupe Sciences En Questions, Paris, Inra, 20 Mars 2003 , 2003 .

[33]  D. L. Simms,et al.  Normal Accidents: Living with High-Risk Technologies , 1986 .

[34]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[35]  David I Blockley Man Made Disasters (Second Edition) , 1999 .

[36]  I. Svedung,et al.  Graphic representation of accident scenarios: mapping system structure and the causation of accidents , 2002 .