The overall goal of accident investigation is to determine the circumstances and causes behind an accident with the aim of improving safety and avoiding future accidents.
The aim is not to determine responsibility for the accident. Nor is the aim to place blame, except in cases where it is necessary to achieve the overall purpose. The core of all investigations is to identify the role played by each individual in the so-called socio-technical system.
You can see the Socio-Technical System here (in Danish - opens in a new window).
The concept behind the Socio-Technical System is based on numerous frameworks in the field of Human Factors: SHEL (Hawkins, 1987) and Reason's (1990) Accident Causation and generic error-modeling system (GEMS) frameworks, as well as Rasmussen's Taxonomy of Error (1987). The new view on the subject provides a much broader spectrum in which actual trends and causes can be identified in order to ensure that repeat instances do not occur.
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Good advice and tips, based on typical errors committed during an investigation, will also contribute to focusing efforts and resources more effectively, thereby achieving a successful implementation of relevant and practical actions.
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Human and technical factors in tandem can be the cause of an accident. |