Identifying pan-industry common contributors to major accident events

Abstract

Analysis of incident investigation findings as a means of identifying common precursors or causal factors is a common topic of safety research. Historically this type of research has been conducted through a single lens, depending on the researcher’s discipline, with incidents analysed in accordance with a favoured theory, or grouped according to industry or region. This has led to the development of numerous frameworks and taxonomies that attempt to predict or analyse events at various levels of granularity. Such theories and disciplines include safety culture and climate, human factors, human error, management systems, systems theory, engineering and design, chemistry and maintenance. The intent of such research is ostensibly to assist organisations in understanding the degree to which their operations are vulnerable to known precursors or causal factors to major accident events and to take proactive measures to improve the safety of their operations. However, the discipline-specific nature of much of this research may limit its application in practice. Specific frameworks and taxonomies may be of assistance when organisations have identified a relevant area of vulnerability within their operations, but are unlikely to assist organisations in identifying those vulnerabilities in the first place. This paper seeks to fill that gap. A multidisciplinary approach was taken to identify common causal factors. Investigation reports published by independent investigation agencies across various industries were analysed to determine common causal factors regardless of discipline or industry.