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|Title:||Guidelines for Safety Investigations of Accidents|
|Authors:||DECHY Nicolas; DIEN Yves; FELICIO Antonio; FUNNEMARK Espen; HARMS-RINGDAHL Lars; LE COZE Jean-Christophe; LOGTENBERG Henk; ROED-LARSEN Sverre; STOOP John; SVEDUNG Inge; TAYLOR Roger; VALVISTO Tarja; VETERE ARELLANO Ana Lisa|
|Publisher:||© ESReDA 2009|
|JRC Publication N°:||JRC55167|
|Abstract:||These guidelines have been prepared for investigators, investigation managers, people who order investigations, responsible persons who will have to learn from the event, victims and researchers. These guidelines provide a minimum, current and recognised cross-sectorial best practices oversight to conduct investigations related to industrial, technological and organisational events. These guidelines give practical and theoretical advices related to the different stages of such investigations. In-depth analysis of accidents, incidents and crises clearly showed that any event is generated by direct or immediate causes (technical failure and/or ¿ "human error"). Nevertheless their occurrence and/or their development is considered to be induced, facilitated or accelerated by underlying organisational conditions (complex factors) found in socio-technical system and organisational networks. It implies to deal with different natures of causalities: mechanistic met in technical installations and more complex met in human and social systems. Addressing those causalities requires various competencies (with disciplines from exact sciences, to engineering and social sciences) to investigate and to learn from an accident. Accident investigation can be performed for various reasons and objectives. They depend on the stakeholders (many types among companies, authorities, or public parties) and their perspectives. Several investigations could often be managed simultaneously (e.g. judicial, technical,¿) and it may lead to interest and operational conflicts such as the access to the accident scene and witnesses, the collection of the facts, the preservation of evidence, the findings, the communication of findings,¿ Corporate, political, cultural and societal requirements will shape the context in which the investigation is conducted. This should be cleared and stated when defining the mandate of the investigation. Despite all this variety of contexts, investigation obeys to general principles (protocols, coordination, competence, data and evidence, reporting, follow-up of lessons learned and communication) and to process phases (defining terms of reference, appointing team, collecting data, hypotheses generation, analysis, findings and recommendations). Connection between phases is not a linear process but rather an iterative one. Any investigator gets skills and know-how, so accident investigation is influenced by a priori knowledge or initial models. Specific methodologies have been developed to facilitate some investigation tasks. They use different logical constructions, different underlying models, and address different levels of phenomena with various perspectives (what happened, why it happened and what is recommended to prevent its repetition). Organisations should prepare their protocols and train their investigators before the event occurs in order to be ready to undertake the investigation in an effective way. These guidelines aim to support those processes. To communicate during and after the investigation process is an important issue. Aim is to provide stakeholders with findings through a report or other supports in order to initiate and facilitate the learning process. Many barriers to learn lessons can be faced by organisations. Turning findings into recommendations (corrective measures) is a specific task that requires specific knowledge of the organisational network and the socio-technical system behaviour. The corrective measures can be challenged by reality and a specific follow-up should be put in place. Finally, some future challenges that would have to be addressed by the investigation and safety management communities conclude the present guidelines.|
|JRC Institute:||Institute for Energy and Transport|
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