Analysis, Causality and Proof in Safety Investigations
Summary
The quality of a safety investigation's analysis activities
plays a critical role in determining whether the investigation is
successful in enhancing safety. However, safety investigations
require analysis of complex sets of data and situations where the
available data can be vague, incomplete and misleading. Despite its
importance, complexity, and reliance on investigators' judgements,
analysis has been a neglected area in terms of standards, guidance
and training of investigators in most organisations that conduct
safety investigations.
To address this situation, the Australian Transport Safety
Bureau (ATSB) developed a comprehensive investigation analysis
framework. The present report provides an overview of the ATSB
investigation analysis framework and concepts such as the
determination of contribution and standard of proof. The report
concludes by examining the nature of concerns that have been raised
regarding the ATSB analysis framework and the ATSB's consideration
of these concerns.
The ATSB believes that its investigation analysis framework is
well suited to its role as an independent, no-blame safety
investigation body. It is hoped and expected that ongoing
development and provision of information about the framework can
help the safety investigation field as a whole consider some
important issues and help develop the best means of conducting
safety investigations to enhance future safety.
Download Complete Document:
ar2007053 [
PDF: 3.92MB]
Type: Research and Analysis Report
Author(s): Michael B. Walker and Kym M. Bills
Series Number: 2007053
Publication Date: 26/06/2008
Publication Number: 08196