Premises in Safety: Accident Investigation Theory
Safety professionals understand premises that exist and apply theories to prevent and determine accident causation. According to Saari (n.d.), accident causation remains a complex process that requires analysis to improve accident prevention. Since safety lacks a basis of theory, the methodology remains an art instead of a science. Throughout time understanding accident occurrences have evolved and presented merit with the development of several models.
Many processes within the safety profession's toolkit seek to determine what went wrong and correct it before another occurrence happens. Throughout the past few decades, safety methodologies established a new baseline. It remains debatable whether history repeats itself or safety theory has evolved into a science. Steps toward practical science applications should enable the identification of a mishap before it happens. Only time will tell whether we have this capability to prevent the accident before it occurs.
Early Days
Accident models used before 1960 were relatively unsophisticated. For example, during early mail delivery, planes crashed, and the investigation focused on equipment failure. According to Rankin (n.d.), in early 1903, 80% of the accidents were created by equipment failure and 20% human error. Today, 80% of accidents relate to human error and 20% as a result of equipment failure. Over time, inquiries determined why the equipage failed and developed prevention methods to reduce risk and eliminate the hazard.
Eventually, theory moved away from equipment failure as a result of engineering reliability. Safety engineering utilizes prevention through design theory that designs out the hazards during the design and construction phase (Brauer, 2016). Later, the emphasis moved to discover why human performance leads to the accident. Many articles and accident reports utilize the term pilot error. Search the National Transportation Safety Board (NTSB) accident database, and thousands of accidents note the probable cause as a pilot or human error. However, the discovery of accident causation requires a deeper dive into the analysis.
Investigation Philosophy Change
The basics of accident analysis introduced fatigue, skill, personality, and motivation elements. Early prevention attempts identified the main concerns: human error, technology, and environmental (Sarri, n.d.). Today, the National Transportation Safety Board (NTSB) utilizes a similar model to discover the event's reason. Investigations determine the probable cause, contributing factors, or reason for the transportation accident. The NTSB process requires documenting recommendations to prevent future occurrences.
Determining why an accident happened afterward represents a reactive method that supported the 20th-century safety process. However, reactive measures are necessary as the NTSB forwards recommendations to the Federal Aviation Administration (FAA) to implement into a law. A balance should exist that includes proactive and reactive safety methods.
Late 1980s
Later in the 20th century, attempts to determine cause created frameworks to determine why human failure evolved. The process went beyond blaming individual failure that resulted in the accident cause. Instead, the analysis focused on the task and steps to determine why human performance suffered and the pilot lacked the required skill.
For example, the Colgan accident started the process for rulemaking that added additional pilot training to enhance airline safety. Human error resembled the area of interest concerning the accident cause. The FAA (2013) mentions that Colgan Air 3407 accident in February 2009 enhanced airline safety and addressed pilot training. The final rule required:
- Pilot recovery from airplane stalls and upset recovery
- Process development to track remedial training for pilots with performance problems
- Training with more pilot monitoring
- Runway safety procedures
- Crosswind and gusty wind training
Using each of the four premises offers meaning to prevent the next accident. Many safety models include each of the premises that provide a roadmap to uncover the next mishap or investigate the probable cause that created the event. Safety oversight presents an awareness of potential circumstances that may occur. Realistically, finding the golden nugget resembles searching for the needle in the haystack. It is questionable what the needle resembles. Therefore, identifying the hazard that remains beneath the surface becomes a daunting task to find and mitigate.
Final Note
Using accident theories and models helps prepare an organization to identify hazards through a risk assessment. Models and theories present a process to identify the accident beforehand, hopefully. Accident prevention requires identifying unsafe acts and working conditions. Searching and seeking to identify unsafe acts and conditions provides insight to identify danger that threatens the workforce's wellbeing. Each premise highlights that accidents involve cause, unsafe conditions and acts, consequences, and likelihood and severity. Aligning premises with accident investigation theory promotes an effective mechanism to identify future hazards and reduce danger proactively.
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References
- Brauer, R. (2016). Safety and health for engineers (3rd ed.). Wiley.
- Federal Aviation Administration. (2013). FAA issues final rule on pilot training. https://www.faa.gov/news/press_releases/news_story.cfm?newsId=15314
- Rankin, W. (n.d.). Investigation process. Boeing Magazine. https://www.boeing.com/commercial/aeromagazine/articles/qtr_2_07/AERO_Q207_article3.pdf
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