Accident investigation: From searching direct causes to finding in-depth causes - Problem of analysis or/and of analyst?

Safety Science

Volumn 50, Issue 6, 2012, Pages 1398-1407

  Dien, Yves ^a   Dechy, Nicolas ^b   Guillaume, Eve ^c  

^a EDF R AND D   (France)

^b INSTITUT NATIONAL DE L ENVIRONNEMENT INDUSTRIEL ET DES RISQUES INERIS   (France)

^c DELFT UNIVERSITY OF TECHNOLOGY   (Netherlands)

Author keywords

Accident; Event root cause; Industrial safety; Organisational analysis

Indexed keywords

ACCIDENT INVESTIGATION; EVENT ANALYSIS; EVENT ROOT-CAUSE; FEEDBACK SYSTEMS; INDUSTRIAL COMPANIES; MAIN CHARACTERISTICS; ORGANISATIONAL ANALYSIS;

ACCIDENT PREVENTION; RISK MANAGEMENT;

ACCIDENTS;

ACCIDENT PREVENTION; ARTICLE; CHERNOBYL ACCIDENT; DECISION MAKING; EPISTEMOLOGY; HISTORICAL PERIOD; HUMAN; LEGAL PROCEDURE; OCCUPATIONAL SAFETY; ORGANIZATIONAL THEORY; POLICY; PRIORITY JOURNAL; PROFESSIONAL KNOWLEDGE; RISK ASSESSMENT; RISK MANAGEMENT; RISK REDUCTION; SOCIAL NETWORK; SOCIAL PROBLEM; WHISTLEBLOWING;

EID: 84857796402     PISSN: 09257535     EISSN: 18791042     Source Type: Journal    
DOI: 10.1016/j.ssci.2011.12.010     Document Type: Article

References (68)

1. Bourdeaux, I., Gilbert, C., 1999. Procédures de REX, d'apprentissage et de vigilance organisationnelles: approches croisées. Programme Risques Collectifs et Situation de Crise, éditions CNRS.
2. Bourricaud, F., 1989. Les organisations. In: Joffre, P., Simon, Y. (Eds.), Encyclopédie de gestion, Economica, T2, pp. 2008-2022.
3. Bourrier, M., 1999. Le nucléaire à l'épreuve de l'organisation. PUF.
4. Bourrier, M., 2004. à la recherche d'un second souffle pour les facteurs humains et organisationnels. Revue Contrôle No. 160.
5. CAIB, 2003. Report, vol. 1. National Aeronautics and Space Administration.
6. Crozier, M., Friedberg, E., 1977. L'acteur et le système. éditions du Seuil.
7. Cullen, W.D. [Lord], 2000. The Ladbroke Grove Rail Inquiry. Part 1 and Part 2 Reports. HSE Books, Her Majesty's Stationery Office.
8. de Gaulejac, V., 2006. La société malade de la gestion. éditions du Seuil.
9. Dechy, N., Dien, Y., 2007. Les échecs du retour d'expérience dans l'industrie: problèmes de verticalité et/ou de transversalité ? Conférence IMdR - GRID «Les entretiens du Risque», 13-14 Décembre, Paris.
10. Dechy, N., Dien, Y., Llory, M., 2008. Les échecs du retour d'expérience: problématiques de la formalisation et de la communication des enseignements tirés. Conférence Lambda-Mu 16 de l'IMdR, Avignon, 6-10 Octobre 2008.
11. Dechy, N., Dien, Y., Llory, M., 2010. Pour une culture des accidents au service de la sécurité industrielle. Conférence Lambda-Mu 17 de l'IMdR, La Rochelle, 5-7 Octobre 2010.
12. Dechy N., Dien Y., Funnemark E., Roed-Larsen S., Stoop J., Valvisto T., Vetere Arellano A.L. Results and Lessons Learned from the ESReDA's Accident Investigation Working Group. Safety Science 2012, 50(6):1380-1391.
13. Dejours, C., 2003. L'évaluation du travail à l'épreuve du réel, Collection INRA. Sciences en Questions.
14. Dien Y. Les facteurs organisationnels des accidents industriels. Risques industriels - Complexité, incertitude et décision: une approche interdisciplinaire 2006, 133-174. éditons TED & DOC, Lavoisier. L. Magne, D. Vasseur (Eds.).
15. Dien, Y., Hofseth, C., 2005. Montée en température de l'Excitatrice de l'alternateur le 17 mai 2004: un événement inscrit dans l'organisation, rapport interne EDF R&D.
16. Dien, Y., Llory, M., 2002. Première synthèse de la veille, rapport interne EDF R&D.
17. Dien, Y., Llory, M., 2004. Effects of the Columbia Space Shuttle Accident on High Risk Industries or: Can We Learn Lessons from Other Industries? Hazards XVIII, November 23-25, Manchester.
18. Dien, Y., Llory, M., 2006. Méthode d'analyse et de diagnostic organisationnel de la sûreté, rapport interne EDF R&D.
19. Dien, Y., Pierlot, S., 2006. Cassandre au pays des risques modernes. 29ième Congrès National de Médecine et Santé au Travail, Lyon, 30 mai-2 juin.
20. Dien Y., Llory M., Montmayeul R. Organisational accidents investigation methodology and lessons learned. Journal of Hazardous Materials 2004, 111:147-153.
21. ESReDA Working Group on Accident Investigation (Eds.), 2009. Guidelines for Safety Investigation of Accidents. ESReDA, DNV.
22. Fahlbruch B., Schöbel M. SOL - safety trough organisational leaning: a method for event analysis. Safety Science 2011, 49:27-31.
23. Frantzen, C., 2004. Tango on Asymptote. SRA-E Annual Conference, November 15-17, Paris.
24. Frei, R., Kingston, J., Koornneef, F., Schallier, P., 2003. Investigation tools. In: Context, Proceedings of the JRC/ESReDA 24th Seminar on " Safety Investigation of Accidents" , Petten, The Netherlands, 12-13 May. <>. http://www.nri.eu.com.
25. Geertz, C., 1998. La description dense. In: La description, tome I. Revue Enquête. éditions Parenthèses, vol. 6, pp. 73-105.
26. Groeneweg, J., Van Schaardenburgh-Verhoeve, K.N.R., Corver, S.C., Lancioni, G.E., 2010. Widening the scope of accident investigations. In: Society of Petroleum Engineers Conference on Health, Safety and Environment in Oil and Gas Exploration and Production held in Rio de Janeiro, Brazil, 12-14 April, 2010. SPE, pp. 127-157.
27. Hollnagel E. Cognitive Reliability and Error Analysis Method - CREAM 1998, Elsevier Science, Oxford.
28. Hopkins, A., 2003. Lessons from Longford. The Esso Gas Plant Explosion, seventh ed. CCH Australia Limited.
29. Hopkins, A., 2008. Failure to Learn: the BP Texas City Refinery Disaster. H Australia Limited.
30. INSAG, 1991. Safety Culture. Safety Series No. 75-INSAG-4. IAEA.
31. Johnson, W.G., 1973. Management and Oversight Risk Tree. US Atomic Energy Commission.
32. Lagadec, P., 1994. La gestion des crises, 3ième éd. Ediscience international.
33. Laporte T., Consolini P. Working in practice but not in theory: theoretical challenges of " High-Reliability Organizations" . Journal of Public Administration Research and Theory 1991, 1(1):19-47.
34. Le Coze, J.-C., Dechy, N., 2007. The organisational side of major accidents: some thoughts on the difficulties of making it operational. In: Proceedings of the Loss Prevention 2007 Conference, Edinburgh, UK, 22-24th May, 2007.
35. Lecoze, J.-C., Dechy, N., Lim, S., Leprette, E., Branka, R., 2005. The 27 march 2003 Billy-Berclau accident: A technical and organizational investigation. In: Proceedings of the 39th Annual Loss Prevention Symposium - AIChE 2005 Spring National Meeting, April 10-14, 2005, Atlanta, GA.
36. Leveson N. A new accident model for engineering safer systems. Safety Science 2004, 42:237-270.
37. Llory, M., 1996. Accidents industriels: le coût du silence. Opérateurs privés de parole et cadres introuvables. éditions L'Harmattan.
38. Llory M. Ce que nous apprennent les accidents industriels. Revue Générale Nucléaire 1998, 1:63-68.
39. Llory, M., 1999. L'accident de la centrale nucléaire de Three Mile Island. éditions L'Harmattan.
40. Llory, M., Dien, Y., 2010. L'analyse organisationnelle de la sécurité des systèmes complexes à risques. Techniques de l'Ingénieur, AG 1577.
41. Llory, M., Montmayeul, R., 2010. L'accident et l'organisation. éditions Préventique.
42. Llory, M., Dien, Y., Pierlot, S., 2007. Les leçons des risques industriels: répétitions insistantes et illusions rétrospectives, Séminaire «Risques industriels majeurs, sciences humaines et sociales», Toulouse, 6-7 décembre.
43. Llory, M., Dien, Y., Pierlot, S., Dechy, N., 2009. Are lessons learned from accidents and are potential improvements implemented? In: Proceedings of the 36th ESReDA Seminar on Lessons Learned from Accident Investigations. EDP, Coimbra, Portugal, 2-3 June 2009.
44. Macrae, C., 2007. Interrogating the Unknown: Risk Analysis and Sense Making in Airline Safety Oversight. Discussion Paper. The Centre for Analysis of Risk and Regulation.
45. Okstad E., Jersin E., Sklet S., Tinmannsvik R.K. Accident investigation in the Norwegian Petroleum Industry - common features and future challenges. Safety Science 2012, 50(6):1408-1414.
46. Ombredane, A., Faverge, J.M., 1955. L'analyse du travail: facteur d'économie humaine et de productivité. PUF.
47. Perrow, C., 1982. The president's commission and the normal accident. In: Sills, D.L., Wolf, C.P., Shelanski, V.B. (Eds.), A Westview Special Study: Accident at Three Mile Island: The Human Dimensions. Boulder, Colorado, pp. 173-184.
48. Perrow, C., 1984. Normal Accidents. Living with High-Risk Technology. Basic Books.
49. Presidential Commission on the Space Shuttle Challenger Accident, 1986. Report to the President by the Presidential Commission on the Space Shuttle Challenger Accident. Government Printing Office.
50. Rasmussen J. Risk management in a dynamic society: a modeling problem. Safety Science 1997, 27(2/3):183-213.
51. Rasmussen J., Svedung I. Proactive Risk Management in a Dynamic Society 2000, Swedish Rescue Services Agency, Karlstad.
52. Reason J. The age of organisational accident. Nuclear Engineering International 1990, 35:18-19.
53. Reason J. Managing the management risk: new approaches to organisational safety. Reliability and Safety in Hazardous Work Systems 1993, 7-22. Hove Lawrence, Erlbaum. B. Wilpert, T. Quale (Eds.).
54. Reason, J., 1997. Managing the Risks of Organizational Accidents. Ashgate, Aldershot.
55. Rochlin, G., Laporte, T., Roberts, K., 1987. The self-designing high-reliability organization: aircraft carrier flight operations at sea. Naval War College Review, pp. 76-90.
56. Roed-Larsen, S., Stoop, J., Funnemark, E. (Eds.), 2005. Shaping Public Safety Investigations of Accidents in Europe. ESReDA, DNV.
57. Sagan S. Toward a political theory of organizational reliability. Journal of Contingencies and Crisis Management 1994, 2(4):228-240.
58. Sklet, S., 2002. Methods for Accident Investigation. Report ROSS (NTNU) 200208.
59. Sklet S. Comparison of some selected methods for accident investigation. Journal of Hazardous Materials 2004, 111:29-37.
60. Svedung I., Rasmussen J. Graphic representation of accident scenarios: mapping system structure and the causation of accidents. Safety Science 2002, 40:397-417.
61. Turner B., Pidgeon N. Man-Made Disasters 1997, Butterworth Heinemann. second ed.
62. US CSB, 2007. Investigation Report. Refinery Explosion and Fire. BP - Texas City, Texas, Report No. 2005-04-I-TX, March 23, 2005.
63. Valvisto, T., Harms-Ringdahl, L., Kirchsteiger, C., Røed-Larsen, S. (Eds.), 2003. Accident Investigation Practices, Results from a European Inquiry. ESReDA, DNV.
64. Vaughan D. The Challenger Launch Decision. Risky Technology, Culture, and Deviance at NASA 1996, The University of Chicago Press.
65. Vaughan D. The trickle-down effect: policy decisions, risky work, and the challenger tragedy. California Management Review 1997, 39(2):80-102.
66. Vaughan D. System effects: on slippery slopes, repeating negative patterns, and learning from mistake. Organization at the Limit. Lessons from the Columbia Disaster 2005, 41-59. Blackwell Publishing Ltd. W. Starbuck, M. Farjoun (Eds.).
67. Weick K.E. Making sense of blurred images: mindful organizing in mission STS-107. Organization at the Limit: Lessons from the Columbia Disaster 2005, Blackwell Publishing. W.H. Starbuck, M. Farjoun (Eds.).
68. Wilpert B., Fahlbruch B. Safety related interventions in inter-organisational fields. Safety Management - The Challenge of Change 1998, 235-248. Pergamon, Elsevier Science Ltd., Oxford. A. Hale, M. Baram (Eds.).