"What we identify as causes depends on whom we are communicating to, on the assumed contrast cases or causal back-ground for that exchange, and on the purposes of the inquiry. Thus, the subset of contributors to an incident or disaster that are seen as causal will be different depending on the purposes of the investigation.- If the investigation takes place for liability purposes, the concerns will be to decide who pays for damages or consequences, how to limit liability judgments, or how to deflect responsibility for damages to other parties.
- If it is done for funereal purposes, the concerns will be how do we put the losses, often very personal losses, behind us, reassert our faith and trust in using the implicated operational system, and resume normal activities (e.g., after an aviation disaster, people still need to get back on an airplane and make use of air transport systems).
- If it is done for political (power) purposes, incidents may be used as clubs or levers in struggles for control within or across organizations.
- But if the goal is improving the reliability of the distributed human-machine system, the concerns should be to learn about how the overall system is vulnerable to failure, to develop effective strategies for change, and to prioritize investment.
Perhaps the greatest clue to the reliability of an organization lies in its reaction to failure.
Do not use investigations simply to justify the organization's motives (all of us, wherever placed in an organization, want to and try to do a good job).
Do not investigate with the a priori goal of finding out how others failed."
Quote from 'The Complexity of Error', page 173 onwards in
'Behind Human Error: Cognitive Systems, Computers, and Hindsight'.
This is a "heavy weight" technical review, but essential reading for those wishing to discuss aspects of human performance.
and a link from another discussion:
http://www.safer.healthcare.ucla.edu...lPrimerDoc.pdf