Are safety investigations pro-active?

This paper elaborates on the debate whether safety investigations are obsolete and should be replaced by more modern safety assessment approaches. Despite their past performance, in particular in aviation, accident investigations are criticized for their reactive nature and the lack of learning potential they provide. Although safety management systems are considered a modern method with a more prospective potential, they too are hard to judge by their quantitative performance. Instead of measuring both concepts along the lines of their output, this contribution explores the origin, context and notions behind both approaches. Both approaches prove to be adaptive to new developments and have the ability to shift their focus towards learning and cognition. In assessing their potential, accident investigations prove to cover a specific domain of application in the risk domain of low probability and major consequences, fulfilling a mission as public safety assessor. In order to make optimal use of their analytic and diagnostic potential, investigations should mobilize more complex and sophisticated scientific theories and notions, in particular of a non-linear nature. Consequently, they are neither reactive, nor proactive, but provide a specific approach to safety issues.     

The criminalization of human error in aviation and healthcare: A review

This review explores the social causes and psychological and organizational consequences of the criminalization of human error in aviation and healthcare. Increasing prevalence of criminal prosecution is seen as a threat to the health and safety of employees and entire safety–critical systems in many industries, but initiatives to counter or mitigate the trend are local and haphazard. Social causes such as a greater societal risk consciousness and intolerance of failure are examined, as well as organizational consequences for disclosure and incident reporting. Psychological consequences of the criminalization of human error are evaluated in terms of employee ill-health, an area that is under-investigated. The criminalization of professional mistakes seems to be an increasingly prevalent phenomenon at the intersection of safety work, sociology, criminology and legal as well as social justice. This paper reviews possible research directions into the criminalization of professional mistake in aviation and healthcare, in the hope of stimulating debate and eventually legitimating it as a topic of study in its own right.     

The effects of different strains of zooxanthellae on the secondary-metabolite chemistry and development of the soft-coral host Lobophytum compactum

We have assessed the secondary-metabolite chemistry of freshly metamorphosed coral polyps, with and without zooxanthellae, using extremely sensitive electro-spray and Fourier-transform mass spectrometry. Coral larvae of the soft coral Lobophytum compactum of the same genetic background were reared, then inoculated with zooxanthellar strains of different taxonomic and geographic origin, and their terpenoid chemistry analysed. The identification of isolobophytolide in individuals of all treatment groups, including aposymbiotic control polyps, demonstrates that control of terpene production lies with the host coral and not their symbiotic algae. Received: 29 November 1999 / Accepted: 22 November 2000     

Reconstructing human contributions to accidents: the new view on error and performance

PROBLEM: How can human contributions to accidents be reconstructed? Investigators can easily take the position a of retrospective outsider, looking back on a sequence of events that seems to lead to an inevitable outcome, and pointing out where people went wrong. This does not explain much, however, and may not help prevent recurrence. METHOD AND RESULTS: This paper examines how investigators can reconstruct the role that people contribute to accidents in light of what has recently become known as the new view of human error. The commitment of the new view is to move controversial human assessments and actions back into the flow of events of which they were part and which helped bring them forth, to see why assessments and actions made sense to people at the time. The second half of the paper addresses one way in which investigators can begin to reconstruct people's unfolding mindsets. IMPACT ON INDUSTRY: In an era where a large portion of accidents are attributed to human error, it is critical to understand why people did what they did, rather than judging them for not doing what we now know they should have done. This paper helps investigators avoid the traps of hindsight by presenting a method with which investigators can begin to see how people's actions and assessments actually made sense at the time.     

The complexity of failure: Implications of complexity theory for safety investigations

Complexity theory suggests that we see performance as an emergent property, the result of complex interactions and relationships. This can clash, however, with what stakeholders see as legitimate and normal in accident investigations. When systems fail, it is still common to blame components (e.g. human errors) and when they succeed spectacularly, to think in terms of individual heroism (e.g. the A320 Hudson River landing). In this paper, we lay out the contrast between a Newtonian analysis of failure that can be recognized in many efforts at safety analysis and improvement. It makes particular assumptions about the relationship between cause and effect, foreseeability of harm, time-reversibility and the ability to produce the “true story” of an accident. With inspiration from complexity theory, failures are seen as an emergent property of complexity. We explore what that means for safety science and work towards a post-Newtonian analysis of failure in complex systems.