Subsequent Accident Research Articles

Interface changes causing accidents. An empirical study of negative transfer

When expert operators interact with a new device, they inevitably reuse former interaction modes and actions. This phenomenon is due to the human cognition seeking resources savings. Schemas support this strategy and are implemented in such a way that perfection is disregarded at the profit of an intuitive trade-off between performance and cognitive resources savings. As a consequence, humans have a strong inclination to fit well-known solution procedures into new problems. For this reason, changes in work environments can cause accidents when they allow operators to interact with a new device if the latter is erroneously perceived as familiar. This research issue originates from an industrial background. The suspected cause of a fatal error performed by an operator in a steelworks factory is replicated in an experiment. The results support the hypothesis according to which errors (and possible subsequent accidents) due to changes in the interface are more likely when the latter does not inhibit former modes of interaction modes. This main result is discussed under the angle of cognitive ergonomics and used as a basis to provide design guidelines.

Using traffic conviction correlates to identify high accident-risk drivers

One of the primary missions of the California Department of Motor Vehicles is to protect the public from drivers who represent unacceptably high accident risks. Optimum fulfillment of this objective requires the development and implementation of strategies for identifying high-risk drivers. One such system in California is the department’s negligent operator point system. This system assigns points to moving violations and accidents and authorizes the department to take driver control actions against drivers who meet the prima facie definition of a negligent operator. The present study explored the viability of predicting accidents from equations constructed to predict convictions for the general driving population. Equations or models that better identify drivers at increased risk of future accident involvement would increase the number of accidents prevented through post license control actions. Although the results did not support prior findings that equations keyed to citations do as well as or better than equations keyed to accidents in predicting subsequent accident involvement, a canonical correlation approach considering subsequent accident and citation rates simultaneously produced a 14.9% improvement in the classification accuracy or “hit rate” for identifying accident-involved drivers.

Mutual misconceptions between designers and operators of hazardous systems

An important causal factor in many failures of complex engineered systems and the subsequent accident sequences is a mismatch between the intentions of the system designers and operators. A study was conducted of the misconceptions that designers appeared to have about operators' intentions and the operating environment, and the misconceptions that operators had about the system's design or the designers' intentions. Inferences about these mutual misconceptions were made from a set of accident investigations in the marine, offshore and onshore process industries. The result was a taxonomy of misconceptions that suggested a variety of systematically flawed assumptions in the decision making of both designers and operators. A prompting tool was developed to help both designers and operators structure the examination of their assumptions. This tool was assessed in conjunction with 20 firms operating or designing hazardous installations in a range of industries.

Insulin sensitivity markers: Predictors of accidents and suicides in Helsinki Heart Study screenees

The purpose of this study was to evaluate whether elements signifying relative insulin sensitivity (IS) were prospectively linked to accidents and suicides in 14,976 Helsinki Heart Study (HHS) screenees. The main outsome measure was hospitalizations and deaths from accidents and suicide attempts determined from Finnish registries, in aggregate; and separating out suicides (and attempts). Cox proportional hazards regression was used to determine adjusted risk ratios (RR) relating IS characteristics (extreme quartiles of high HDL-C, low BMI, and low SBP), individually and conjointly, to subsequent accidents or suicides (including attempts), adjusted for age, alcohol use, smoking, and non-HDL cholesterol. Each IS element was related to combined hospitalization and death, from accidents and from suicide attempts; increasing numbers of these characteristics were associated with increased risk, an effect that was more powerful and statistically significant for suicide. For accidents, the presence of one and two to three IS characteristics provided RRs (95% confidence intervals (CI)) of 1.08 (0.97–1.20) and 1.14 (0.98–1.31), respectively. For suicides including attempts, RRs (95%CI) were 1.61 (1.09–2.38) for one IS factor, and 1.88 (1.18–2.98) for two to three IS factors, while for completed suicides, the figures were 2.01 (1.19–3.38) and 2.24 (1.20–4.17), respectively. We speculate that insulin sensitivity may relate to these outcomes through low central serotonin activity.

Previous convictions or accidents and the risk of subsequent accidents of older drivers

The over-involvement of elderly drivers in collisions has a potentially adverse effect on highway safety. The question for most experts in traffic research is whether we can predict the individual risk of accidents and which variables are the best predictors, especially for this population. For a better understanding of the elderly drivers’ problems, this study aimed to describe the most common types of accidents in the elderly population of drivers living in Quebec (≥65 years of age). The second objective of the study was to analyse the relationship between previous accidents or convictions and the risk of subsequent accidents. The results show that: (1) elderly drivers are characterised by error accidents involving more than one car, especially at intersections, (2) prior accidents are a better predictor for accident risk than prior convictions and (3) these trends steadily increase with each age group (drivers 65 years old to 80 years or more). The results are discussed in relation to the literature on risk behaviour of the elderly drivers.

Improving Incident Reports Using a Schematic Recall Aid: The Critical Event Reporting Tool (CERT)

Incident reports are intended to help identify problems in safety critical systems and aid in preventing subsequent accidents, thus improving safety. Unfortunately, incident-reporting forms are generally unstructured, providing little guidance to the reporter on how to describe the critical events of an incident. As a result, most reports contain information on what happened, as opposed to why an incident happened, and hence make the identification of intervention and prevention strategies onerous. The purpose of the present study was to help remedy this situation by developing and testing a tool, coined the Critical Event Recall Tool (CERT) for improving the quality of information contained in narrative reports of incidents. Results of this study indicate that CERT improved the analytical content of general aviation pilots' reports of a critical incident that occurred during a simulated cross-country flight and that pilots who used CERT generally felt that the tool was easy to use and understand.

Evaluation of High Temperature Tensile and Creep Properties of Light Water Reactor Coolant Piping Materials for Severe Accident Analyses

It has been pointed out that the reactor coolant system piping could fail prior to the meltthrough of the reactor pressure vessel in a high pressure sequence of pressurized water reactor severe accidents. In order to apply to the evaluation of the piping failure which influences the subsequent accident progression, models for the strength of piping materials at high temperatures were examined. It was found that 0.2% proof stress and ultimate tensile strength above 1,073 K obtained from tensile tests was reproduced by a quadratic equation of the reciprocal absolute temperature. Short-term creep rupture time and minimum creep rate at high temperatures were well correlated by the modified Norton's Law as a function of stress and temperature, which implicitly expressed the effect of the precipitation and the resolution of precipitates on the creep strength. The modified Norton's Law gave better results than the conventional Larson-Miller method. Relating applied stress vs. minimum creep rate and tensile properties vs. applied strain rate obtained from the creep and tensile tests, a temperature range where the dynamic recrystallization significantly occurred was evaluated.

Driving in adults with refractory localization-related epilepsy. Multi-Center Study of Epilepsy Surgery.

To examine the frequency of driving an automobile and characteristics associated with driving in individuals with refractory localization-related epilepsy. Driving is generally restricted and monitored in people with epilepsy. Little is known about the frequency of driving and subsequent accidents specifically in individuals with uncontrolled epilepsy. In an ongoing, prospective, multicenter study of resective epilepsy surgery, individuals were interviewed when they presented for surgical evaluation. Analyses were conducted using chi-square, t-tests, and multiple logistic regression. Of 367 eligible participants, 115 (31.3%) had driven in the last year, most on at least a weekly basis. In a multivariable analysis, factors associated with an increased likelihood of driving were having a current license (OR = 10.71, p < 0.001) and ever having had a license (OR = 3.86, p = 0.003). Younger individuals were also more likely to drive. Lower levels of driving were found in women (OR = 0.31, p < 0.001), individuals who were self-described as disabled (OR = 0.20, p < 0.001), and those who were employed full-time (OR = 0.43, p = 0.03) or part-time (OR = 0.15, p = 0.005). At some point in the past, 144 individuals experienced one or more seizures while driving, and 98 experienced at least one accident because of a seizure. Of those who had accidents, 94% reported property damage, 32% had an injury, and 20% caused injury to others. Despite restrictions, almost one third of individuals with refractory epilepsy drive. Understanding why they do may help identify means of modifying this behavior or identifying services that, if provided, would help people with uncontrolled epilepsy forego driving.

Astereopsis Caused by Traumatic Brain Injury

Impaired depth perception (astereopsis) has been observed in a variety of cerebral pathologies affecting the posterior parietal lobe. In the current study of 93 consecutive head trauma admissions, 24% had complete astereopsis and 41% performed more than 2 SDs below the orthopedic control group mean. Degree of impairment was related to Glascow Coma Scale score, length of posttraumatic amnesia, reduced visuospatial and memory abilities, and the presence of intracranial pathology of the parietal lobes. Impairment was also related to trauma severity in patients without any visualized intracranial pathology, presumably due to diffuse axonal shearing. Clinically meaningful impairment was observed in 25% of this group; 10% had complete astereopsis. Stereoacuity screening requires 1 to 2 minutes. Undetected astereopsis may increase risk for subsequent motor vehicle accidents or falls.

Contributory factors to traffic accident deaths identified at coroner's inquest.

Road traffic accidents (RTAs) are an important public health problem and the collection of local information is central to successful accident initiatives in a district. As the local coroner is responsible for investigating accidental deaths, the coroner's inquest files are a potentially useful source of information in developing a district strategy to reduce accidents. A consecutive series of fatal RTAs occurring within the city of Liverpool (1990-1992) were identified and the inquest records of the city coroner reviewed retrospectively to describe the local pattern of fatal RTAs and identify contributory factors. A total of 95 deaths were reviewed. Deaths predominantly involved pedestrians (72) and private cars (70), on roads where the speed limit was 30 m.p.h. (75), often on the main arterial roads of the city (53). Important contributory factors included alcohol consumption by the fatality (31), unsafe driving (31), unlit street lighting at night (16), and pedestrians failing to look (12). Both alcohol consumption and unsafe driving prominently involved younger adult males. More than two-thirds (64/95) of deaths had one or more contributory factors identifiable from inquest records. Coroner inquest records provide a useful source of information to identify opportunities and priorities for preventing fatal RTAs in a district. The subsequent accident strategy for Liverpool, part of the City Health Plan, advocates a co-ordinated approach that includes engineering measures to reduce vehicle speeds and protect pedestrians, measures to address driver attitudes, and the enforcement of current legislation in relation to alcohol and speeding.

Prediction of police officers' traffic accident involvement using behavioral observations

The current study used scores on the Driver Performance Measurement (DPM) test and data gathered over four years on accident type and frequency from 47 police officers to provide evidence that cognitive-behavioral observations of driving patterns can lead to predictions of subsequent accident involvement. Results indicate that after controlling for age and experience, scores on the DPM test predicted involvement in preventable accidents but not unpreventable accidents. Implications for future research involving the observation of cognitive-behavioral sequences are discussed.

Recall of traumatic memories following cerebral vascular accident

We present a case of delayed post-traumatic stress disorder (PTSD) in a WWII combat veteran who developed symptoms following medical retirement. Following a subsequent cerebral accident (CVA) Mr. J experienced intrusive thoughts, recalled forgotten war memories, began avoiding reminders of war (e.g., stopped teaching marksmanship), and experienced dissociative episodes in which he felt as though he was in hand-to-hand combat. Mr. J's example suggests that the disinhibiting sequelae of CVA's, and other neuropsychological deteriorations that are likely to occur with poor health and advancing age, may influence expression of PTSD symptoms.

Safety effects of relaxing california's clean-record requirement for driver license renewal by mail

A pilot program was established in California in 1982 authorizing mail renewal of driver licenses for persons under age 70 lacking clean (accident- and conviction-free) 4-year driving records, but showing clean 2-year records at selection. Such drivers constitute about 14% of California's renewal population, or about 500,000 renewees per year. Eligible drivers whose licenses expired in 1983 were subjects of the present study. Half of them were randomly assigned to a group whose members were sent offers of renewal by mail and the other half were sent standard renewal notices requiring appearance in a field office and successful completion of vision and traffic law tests. Traffic accidents and convictions following the mailout of these documents were tracked for both groups; results presented here cover a 4-year period subsequent to mailout. During this period (a normal license term in California), no significant overall difference was shown between the groups with respect to subsequent convictions or accidents. However, significant detrimental effects on accidents were noted for a subgroup of drivers who had experienced recent traffic violations or accidents which were not on their records at selection. Implications of these results are discussed.

Accidents at sea: Multiple causes and impossible consequences

Accidents are the consequences of highly complex coincidences. Among the multitude of contributing factors human errors play a dominant role. Prevention of human error is therefore a promising target in accident prevention. The present analysis of 100 accidents at sea shows that human errors were not as such recognizable before the accident occurred. Therefore general increase of motivation or of safety awareness will not remedy the problem. The major types of human error that contribute to the occurrence of accidents are wrong habits, wrong diagnoses, lack of attention, lack of training and unsuitable personality. These problems require specific preventive measures, directed at the change of undesired behaviors. Such changes should be achieved without the requirement that people comprehend the relation between their actions and subsequent accidents.

Unemployment, alcohol and injury in West Belfast

The relationship of being employed or not to alcohol consumption and subsequent injury which necessitated hospital treatment was evaluated prospectively in 116 patients coming to the Accident and Emergency Department of a large teaching hospital. Details relating to employment, category and situation of injury were collected prospectively on a standard form and breath alcohol content was evaluated in all subjects. Employment or not was related to alcohol consumption and subsequent associated accidents: 40 per cent of unemployed subjects sustained accidents related to alcohol compared with 8 per cent of employed patients ( P < 0.01 by the χ 2 test). Accidents related to alcohol also tended to occur in public places. These findings represent previously unrecognized associations between employment, alcohol consumption and subsequent accidents.

The contributions of cognitive engineering to the safe design and operation of cam and robotics

Abstract Eberts, R. and Salvendy, G., 1986. The contributions of cognitive engineering to the safe design and operation of CAM and robotics. Journal of Occupational Accidents, 8: 49–67. Many new technologies — numerical control, robotics, flexible manufacturing systems, and computer-aided design (all subsumed under the general heading of computer-aided manufacturing) — are now being incorporated into the manufacturing process. The next several years should see an acceleration of this process. The role of the human operator in these new systems is changing so that the human is now required to perform more cognitive tasks. Assessing the cognitive errors and subsequent accidents is difficult in these new systems. This paper provides a framework for evaluating cognitive errors. First, computer-aided manufacturing tasks are broken down into smaller components. Next, the operator tasks are mapped into three cognitive function areas: attentional resources, decision making, and computer interaction. These three areas are then evaluated in terms of the kinds of errors which can occur, the potential safety hazards, and cognitive engineering solutions to these problems. Recommendations for effective design, for reduction of accidents due to cognitive errors, are provided.

Factors Influencing Health and Safety Performance in New Zealand

Multiple environmental pressures, both internal and external to the organization, are examined as factors influencing the administration of health and safety programmes and subsequent accident performance. Data were collected from seven industrial sectors in New Zealand. Those firms with better safety records indicated that the most influential factors shaping their policies included government rules and regulations and demonstrated employee concerns and demands. The quality of the relationship with the union and the locus of enterprise ownership also play a significant role in the effectiveness of health and safety administration.

The contributions of cognitive engineering to the safe design and operation of CAM and robotics

Eberts, R. and Salvendy, G., 1986. The contributions of cognitive engineering to the safe design and operation of CAM and robotics. Journal of Occupational Accidents, 8: 49–67. Many new technologies — numerical control, robotics, flexible manufacturing systems, and computer-aided design (all subsumed under the general heading of computer-aided manufacturing) — are now being incorporated into the manufacturing process. The next several years should see an acceleration of this process. The role of the human operator in these new systems is changing so that the human is now required to perform more cognitive tasks. Assessing the cognitive errors and subsequent accidents is difficult in these new systems. This paper provides a framework for evaluating cognitive errors. First, computer-aided manufacturing tasks are broken down into smaller components. Next, the operator tasks are mapped into three cognitive function areas: attentional resources, decision making, and computer interaction. These three areas are then evaluated in terms of the kinds of errors which can occur, the potential safety hazards, and cognitive engineering solutions to these problems. Recommendations for effective design, for reduction of accidents due to cognitive errors, are provided.

A driving record analysis of suspension and revocation effects on the drinking-driving offender

Past studies have demonstrated that license suspension or revocation reduces subsequent DUI convictions and traffic accidents of multiple DUI offenders to a greater degree than jail sentences and fines alone, or participation in an alternative alcohol abuse treatment program. This study describes the duration of the impact of recidivism-Ievel-specific licensing actions on DUI offenders at three recidivism levels. Results indicate that the first DUI offender (who receives no licensing action) represents a DUI recidivism and accident risk comparable to the suspended second DUI offender during the year following their respective DUI convictions. Furthermore, additional record entries indicate that at least 32% of suspended second offenders drive during the period of the licensing action; at least 61% of revoked third offenders acquire a record entry during the licensing action. In addition to the results, major program recommendations concerning the first offender and the use of restricted licenses are outlined.

Predicting accident involvement with the motorcycle operator skill test

The present study was conducted to assess the predictive validity of the Motorcycle Operator Skill Test (MOST) developed by McPherson and McKnight (1976). It was anticipated that among licensed motorcyclists those scoring higher on this off-road skill test would be less likely to become involved in an accident than motorcyclists scoring lower. A sample of motorcycle operator licence applicants was administered the MOST in addition to the regular licensing test. These motorcyclists were contacted about a year later and queried about their riding experiences including motorcycle accidents. Driver records were also searched for six months after the motorcyclist was licensed. Although bivariate analyses indicated that high scorers on the MOST were more likely to have had an accident than low scorers, multivariate analyses revealed no effect of test performance on subsequent accident involvement. However, accident likelihood was found to decrease as a function of age and increase as a function of vehicle distance travelled (i.e. exposure to risk).