Effects of a systems approach in occurrence investigations
(2024) FLMU16 20232Division of Risk Management and Societal Safety
- Abstract
- In 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types of investigations are different with a special interest in the effects of the investigations on the organisation.
This research comprises two parts. In part 1 a comparative analysis is conducted on investigation reports — scrutinizing five reports pre-2017 and four reports post-2017. The analytical framework is derived from Hollnagel's... (More) - In 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types of investigations are different with a special interest in the effects of the investigations on the organisation.
This research comprises two parts. In part 1 a comparative analysis is conducted on investigation reports — scrutinizing five reports pre-2017 and four reports post-2017. The analytical framework is derived from Hollnagel's categorization regarding incident investigation models, which delineates three models: sequential, epidemiological, and systemic.
The findings show that there are distinctions in both the nature and effects of the investigation reports. Investigations conducted pre-2017 exhibit characteristics of the sequential model due to a focus on what went wrong, (broken) components and measures that mostly aim at the sharp end operator (train drivers, conductors, train dispatcher) such as training and discussing specific findings of the investigations with those involved only.
Investigations conducted post-2017 exhibit characteristics of the systemic model due to a focus on the central question ‘why did it make sense to do what one did’ (local rationality) implying a focus on work as done and understanding the functional characteristics on the level of the system as a whole, and measures that mostly aim at the system although measures that aim at individuals are still noticeable.
In Part 2 insights into the context and experiences of the effects of the investigations of nine individuals engaged in the investigation process are gathered through interviews. These experiences of the individuals support the conclusions of part 1 and in addition show that before 2017, the investigations were mandatory but did not seem to have a (positive) effect on the level of safety. The investigation process resulted in a feeling of blame and guilt by those involved. The measures of investigations focused mainly on fixing broken components with a focus on human operators (train drivers, conductors and train dispatchers) such as training and informing. After 2017, informants experience that the investigations are adding value to the organisation. Those involved feel a sense of being heard, understood, and recognized. Measures of investigations focus more on the system such as the visibility of trains with still an undertow of human focus regarding training. (Less)
Please use this url to cite or link to this publication:
http://lup.lub.lu.se/student-papers/record/9153670
- author
- Kompeer, Sverre LU
- supervisor
- organization
- course
- FLMU16 20232
- year
- 2024
- type
- H1 - Master's Degree (One Year)
- subject
- keywords
- safety, accident, incident, occurrence, investigation, investigation models, reductionist approach, systemic approach, FLMU06
- language
- English
- id
- 9153670
- date added to LUP
- 2024-05-23 07:04:43
- date last changed
- 2024-05-23 07:04:43
@misc{9153670,
abstract = {{In 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types of investigations are different with a special interest in the effects of the investigations on the organisation.
This research comprises two parts. In part 1 a comparative analysis is conducted on investigation reports — scrutinizing five reports pre-2017 and four reports post-2017. The analytical framework is derived from Hollnagel's categorization regarding incident investigation models, which delineates three models: sequential, epidemiological, and systemic.
The findings show that there are distinctions in both the nature and effects of the investigation reports. Investigations conducted pre-2017 exhibit characteristics of the sequential model due to a focus on what went wrong, (broken) components and measures that mostly aim at the sharp end operator (train drivers, conductors, train dispatcher) such as training and discussing specific findings of the investigations with those involved only.
Investigations conducted post-2017 exhibit characteristics of the systemic model due to a focus on the central question ‘why did it make sense to do what one did’ (local rationality) implying a focus on work as done and understanding the functional characteristics on the level of the system as a whole, and measures that mostly aim at the system although measures that aim at individuals are still noticeable.
In Part 2 insights into the context and experiences of the effects of the investigations of nine individuals engaged in the investigation process are gathered through interviews. These experiences of the individuals support the conclusions of part 1 and in addition show that before 2017, the investigations were mandatory but did not seem to have a (positive) effect on the level of safety. The investigation process resulted in a feeling of blame and guilt by those involved. The measures of investigations focused mainly on fixing broken components with a focus on human operators (train drivers, conductors and train dispatchers) such as training and informing. After 2017, informants experience that the investigations are adding value to the organisation. Those involved feel a sense of being heard, understood, and recognized. Measures of investigations focus more on the system such as the visibility of trains with still an undertow of human focus regarding training.}},
author = {{Kompeer, Sverre}},
language = {{eng}},
note = {{Student Paper}},
title = {{Effects of a systems approach in occurrence investigations}},
year = {{2024}},
}