Just Culture Accident Model

[seagull967]

This paper proposes that the concepts developed for Just Culture may provide an avenue to broaden the scope of accident investigation and move away from the “blame” outcome of most reports through the use of a simple Just Culture algorithm to mitigate cognitive bias on the part of the investigator. Absent a formal strategy, cognitive bias has a high probability of occurring, and becoming integrated into the investigators subconscious during the early stages of an accident investigation. Just Culture is becoming widely accepted, and as such the transition to integrating an investigative model utilizing the concept should be easier to implement and may encounter less political push back than some of the more complex approaches proposed in recent years, yet still provide a robust path to causality and human factors aspects that is more comprehensive than that offered through the traditional models that are still in use by most organizations.

Link to the conference paper

[Musician]

The problem with proposing a new accident investigation model is showing that the one we have is inadequate. The paper claims this: "However, a review of accident reports utilizing a more robust accident model reveals that many of the reports completely missed the actual factors that led to the accident." The support for this is:

1. a reference to Nancy Leveson: Engineering for a Safer World. I've seen the refrenced section in the draft version, and it's basically a very short summary of three other studies.
2. a reference to an analysis of Comair flight 5191, which criticzes the NTSB report thus: "The alternative, to manage performance and to control the sources of performance variability, is not considered." This seems contrafactual, since three of the four main recommendations adress exactly that: "cockpit moving maps or runway alerting systems" help performance management, and "airport surface marking standards" and "ATC policy changes" aim at reducing variability, as I understand it.
3. a discussion of the NTSB report on the 1994 accident of USAir 1016 in Charlotte, which concludes: "That would push the entire investigation towards examining how to better provide accurate information to flight crews so they could make informed decisions." The point falls somewhat flat, as the report gives a lot of weight to these issues in its analysis of probably cause and recommendations. Both the lack of accurate weather information being provided as well as the organizational causes for this lack are being addressed in this report.

It's not convincing me that the existing NTSB reports are deficient.

[seagull967]

There is widespread concern about problems in accident reports and the validity of them. This is not just my opinion, it is shared by many even at NTSB and other investigative organizations around the world. For those that are actively involved in the process it is fairly well known to be a problem. I can understand why most pilots would be unaware of this, as pilots tend to be the worst critics of other pilots. Can you say "fundamental attribution error"?

[Piltdown Man]

This paper contains several flaws. The first is that investigations are stressful and this leads to short-cuts, errors and assumptions. I disagree. This is the job they signed up to do and although some aspects are unpleasant, it's the job. The second, larger flaw, is that investigators are tainted by initial findings. Again I disagree. You keep interviewing, researching, collecting facts and data until you believe you can justify stopping. The cause may not be evident for some time. This is because only after sufficient facts are unearthed (or kindly presented) can the tough job of "why?" can be answered. The fact-finding has to come first followed by an analysis of the facts as found. The 'blame', if any, can only be attributed during the analysis. This is when the difference between a report written by investigators from a Just Culture varies from a one from a hang'em high mob (rotten apple brigade).

[seagull967]

Interesting. Based on personal experience as well as talking to other members of the various parties in several major investigations I have found a much different conclusion. Regardless of what the people "signed up for" the reality is that humans are still humans. What you describe is a perfect world scenario, and of course if you had that one would not gave any accidents to investigate!