Abstract
After paying the high price of an accident, we often miss the following opportunities to learn from it:
•We find only a single cause, often the final triggering event.
•We find immediate causes but not ways of avoiding the hazards or weaknesses in management.
•We list human error as a cause without saying what sort of error though different actions are needed to prevent those due to ignorance, those due to slips or lapses of attention and those due to non-compliance.
•We list causes we can do little about.
•We change procedures rather than designs.
•We do not help others to learn as much as they could from our experiences.
•We forget the lessons learned and allow the accident to happen again. We need better training, by describing accidents first rather than principles, as accidents grab our attention; we need discussion rather that lecturing, so that more is remembered; we need databases that can present relevant information without the user having to ask for it.
Finally, we ask if legislation can produce improvements.
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Kletz, T. (2002). Accident Investigation — Missed Opportunities. In: Redmill, F., Anderson, T. (eds) Components of System Safety. Springer, London. https://doi.org/10.1007/978-1-4471-0173-4_1
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DOI: https://doi.org/10.1007/978-1-4471-0173-4_1
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