The objective of accident reports is to prevent future accidents or incidents, not for academic interest, lawyers, or insurance.
Primary cause etc, might make easy reading for the ‘decision makers’, but does not provide the ‘sharp end’ with an effective means to maintain / improve safety, i.e. what do we have to fix (why), and how.
This report and that for Congonhas, are above average (even if they are difficult to read); Congonhas has greater practicality due to the discussion of human factors (although this was not factual evidence) and that the recommendations aligned with the contributions.
In comparison, the Buffalo report might be more readable, but I doubt that it will have the same effectiveness as the other two. The object is not just to prevent a repeat of the reported accident; it’s the prevention of future ones which should dominate our thoughts.
James Reason provides this view of the elements in accidents (The Human Contribution).
- Universals: the ever present tensions between production and protection.
- Conditions: latent factors that collectively produce defensive weaknesses.
- Causes permit the chance conjunctions of local triggers and active failures to breach all the barriers and safeguards.
“The Universals and Conditions are ubiquitous (
ever-present). Only the local events are truly causal and make the difference between this accident and all the other organizations that remain accident free.
So what are the conditions ….
tools and equipment, safety culture, design and construction, workarounds, management and supervision … ”.
Most if not all of Reason’s
Universals and Conditions can be found in the ‘contributions’ of accident reports. Concentration on ‘cause’ ultimately leads to a solution of ‘not being there’ just to avoid an accident, which is self-defeating and impracticable. However, focus on contributions, the links, and variability in these, provide everyone with a means of improving safety.
Reason’s solution requires checks on the ‘vital signs’ of an operation (SMS?). IMHO this is not a process of analysis of what can / has to be changed; instead there is a need to look at what has changed – the contributions in accidents and the links between them.
Ask what has been overlooked, what has gradually changed and become the norm, what has been accepted as routine, except that it should not be routine.
Many of those small and insignificant changes are the contributions listed in accident reports. These everyday norms are not the ‘cause’ of accidents, but they are the weaknesses in our safety defenses.