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Journal of Safety Research, 7(2), 67-73.
The paper tries to call attention to the need to develop generally acceptable approaches and
analysis methods that will result in complete, reproducible, conceptually consistent, and easily
communicated explanations of accidents. The first step for accident investigation should be to
answer the question, “what happened?” This involves a delineation of the beginning and end of
the accident phenomenon. It is extremely important that a convention for defining precisely the
beginning and end of an accident is decided on and used. The second question to answer is,
“Why did it happen as it did?” This means a recognition of the role of conditions leading to the
accident is necessary. A general explanation of the accident phenomenon is needed. This can be
done using the P-theory of accidents. The theory states that the accident can be seen to begin
with a perturbation and end with the last injurious or damaging event in the continuing accidental
events sequence. Accident event sequences should be displayed to aid accident investigation. An
events charting method is one way to do this. It is a chronological array of events and helps
structure the search for relevant factors and events involved in the accident. A method for
presenting the accident events and enabling conditions is suggested. This method stays tuned into
the time order and logical flow of events present in an accident. The author believes that the
adoption of the P-theory and the charting methods would improve the public’s grasp of accident
phenomenon.
5
Benner, L., Jr. (1982). 5 accident perceptions: Their implications for accident
investigations. Professional Safety, 27(2), 21-27.
The author is interested in investigating what the standards of accident investigation should be. A
common problem is that investigators may each have different ideas as to the purpose of the
investigation in relation to what their own needs and wants may be. Five distinct perceptions of
the nature of accident phenomenon are suggested to exist and the strengths of each are discussed.
These perceptions each seem to lead to a theoretical base for accident investigation. The first
perception is the single event perception, where accidents are treated as a single event. The only
strength of this perception is its tendency to concentrate attention on a single corrective measure.
A major weakness is that it provides an overly simplified explanation of accidents. The second
perception is the chain of events perception which treats accidents as a chain of sequential
events. The main focus is placed on unsafe conditions and acts. The major strength of this
perception is that the reconstruction technique provides some disciplining of the data search by
doing sequential ordering. A weakness is that the criteria for the selection of data used are
imprecise and very unlikely to lead to reproducible results. The third perception is the
determinant variable or factorial perception. This perception tries to discern common factors in
accidents by statistical manipulation of accident data. An important strength here is its ability to
discover previously undefined relationships. A major weakness is the total dependency on data
obtained by accident investigators. The fourth perception is the logic tree perception. This
presumes that converging chains of events lead to an undesired event. The major strength of this
perception is that it provides an approach to organize speculations about accidental courses of
events and allows an operator to watch for initiation events. A weakness is that the beginning
and end of an accident phenomenon are left to be decided by the individual investigators. The
fifth and final perception is the multilinear events sequence perception. This perception treats
accidents as a segment of a continuum of activities. The major strength is the way it facilitates
discovery by structuring data into logical arrays. A weakness is the perceived complexity of the
methodologies which discourages use. Three areas are addressed as problem areas that need to
be improved for accident investigators. Each investigator develops a personalized investigative
methodology instead of having a common methodology used by all investigators. Investigators
have difficulty linking investigations to predicted safety performance of an activity. Finally,
there are no standardized qualifications for investigators.
6
Berninger, D. J. <unknown date>. Understanding the role of human error in aircraft
accidents. Transportation Research Record, 1298, 33-42.
There are two main strategies used to address human error. The first is the introduction of
technology that is intended to assist and reduce the roles of humans. The second is training and
　
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