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Learning from accident investigations – A cross-country comparison

Cedergren, Alexander LU and Petersen, Kurt LU (2010) The 10th International Probabilistic Safety Assessment & Management Conference (PSAM) In Proceedings 10th International Probabilistic Safety Assessment & Management Conference.
Abstract
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... (More)
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. (Less)
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author
organization
publishing date
type
Chapter in Book/Report/Conference proceeding
publication status
published
subject
keywords
Accident investigations, Investigation boards, Learning
in
Proceedings 10th International Probabilistic Safety Assessment & Management Conference.
pages
11 pages
conference name
The 10th International Probabilistic Safety Assessment & Management Conference (PSAM)
external identifiers
  • Scopus:84873598544
language
English
LU publication?
yes
id
a9e00da0-8b5e-45da-8e7d-db8bcd9a7d4c (old id 2374810)
date added to LUP
2012-03-22 08:54:04
date last changed
2016-10-13 05:02:03
@misc{a9e00da0-8b5e-45da-8e7d-db8bcd9a7d4c,
  abstract     = {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<br/><br>
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<br/><br>
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<br/><br>
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.},
  author       = {Cedergren, Alexander and Petersen, Kurt},
  keyword      = {Accident investigations,Investigation boards,Learning},
  language     = {eng},
  pages        = {11},
  series       = {Proceedings 10th International Probabilistic Safety Assessment & Management Conference.},
  title        = {Learning from accident investigations – A cross-country comparison},
  year         = {2010},
}