Alexander Cedergren
Universitetslektor
Learning from accident investigations – A cross-country comparison
Författare
Summary, in English
This paper compares all accident investigation reports covering railway accidents issued by the national investigation boards in Sweden, Norway and Denmark during a two-year period (2008-2009). By using content analysis, units of text describing attributed causes have been selected and categorized as belonging to one of three hierarchical levels; the micro level (technical malfunctioning and human actions), meso level (organizational actions and factors in the physical environment), and
macro level (inter-organizational and regulatory factors). In addition, attributed causes on each level have been further categorized as belonging to different ‘types’ of causes. In a similar manner the recommendations described in all studied reports have been divided into different classes. The results show that the majority of attributed causes in all three countries belong to the micro level, and about
half of all recommendations aim at human factors aspects. Furthermore, the diversity in different ‘types’ of causes differs between the countries. The analysis has been followed up by interviews with
the investigation boards. Based on these interviews, it can be concluded that the structure, mandate and traditions of the investigation boards influences the outcome of the investigations in such way that a broader mandate gives rise to a higher potential for accidents to be examined from multiple perspectives.
macro level (inter-organizational and regulatory factors). In addition, attributed causes on each level have been further categorized as belonging to different ‘types’ of causes. In a similar manner the recommendations described in all studied reports have been divided into different classes. The results show that the majority of attributed causes in all three countries belong to the micro level, and about
half of all recommendations aim at human factors aspects. Furthermore, the diversity in different ‘types’ of causes differs between the countries. The analysis has been followed up by interviews with
the investigation boards. Based on these interviews, it can be concluded that the structure, mandate and traditions of the investigation boards influences the outcome of the investigations in such way that a broader mandate gives rise to a higher potential for accidents to be examined from multiple perspectives.
Avdelning/ar
- Avdelningen för Brandteknik
- Lund University Centre for Risk Assessment and Management (LUCRAM)
- Avdelningen för Riskhantering och Samhällssäkerhet
Publiceringsår
2010
Språk
Engelska
Publikation/Tidskrift/Serie
Proceedings 10th International Probabilistic Safety Assessment & Management Conference.
Dokumenttyp
Konferensbidrag
Ämne
- Social Sciences Interdisciplinary
- Other Civil Engineering
- Building Technologies
Nyckelord
- Accident investigations
- Investigation boards
- Learning
Conference name
The 10th International Probabilistic Safety Assessment & Management Conference (PSAM)
Conference date
2010-06-07 - 2010-06-11
Conference place
Seattle, United States
Aktiv
Published