Learning from accident investigations – A cross-country comparison

Alexander Cedergren, Kurt Petersen

Research output: Chapter in Book/Report/Conference proceedingPaper in conference proceedingpeer-review

Abstract

This paper compares all accident investigation reports covering railway accidents issued by the national investigation boards in Sweden, Norway and Denmark during a two-year period (2008-2009). By using content analysis, units of text describing attributed causes have been selected and categorized as belonging to one of three hierarchical levels; the micro level (technical malfunctioning and human actions), meso level (organizational actions and factors in the physical environment), and
macro level (inter-organizational and regulatory factors). In addition, attributed causes on each level have been further categorized as belonging to different ‘types’ of causes. In a similar manner the recommendations described in all studied reports have been divided into different classes. The results show that the majority of attributed causes in all three countries belong to the micro level, and about
half of all recommendations aim at human factors aspects. Furthermore, the diversity in different ‘types’ of causes differs between the countries. The analysis has been followed up by interviews with
the investigation boards. Based on these interviews, it can be concluded that the structure, mandate and traditions of the investigation boards influences the outcome of the investigations in such way that a broader mandate gives rise to a higher potential for accidents to be examined from multiple perspectives.
Original languageEnglish
Title of host publicationProceedings 10th International Probabilistic Safety Assessment & Management Conference.
Number of pages11
Publication statusPublished - 2010
EventThe 10th International Probabilistic Safety Assessment & Management Conference (PSAM) - Seattle, United States
Duration: 2010 Jun 72010 Jun 11

Conference

ConferenceThe 10th International Probabilistic Safety Assessment & Management Conference (PSAM)
Country/TerritoryUnited States
CitySeattle
Period2010/06/072010/06/11

Subject classification (UKÄ)

  • Social Sciences Interdisciplinary
  • Other Civil Engineering
  • Building Technologies

Free keywords

  • Accident investigations
  • Investigation boards
  • Learning

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