Examining the systemic accident analysis research-practice gap
thesisposted on 17.12.2013, 11:22 authored by Peter Underwood
In order to enhance safety and prevent the recurrence of major accidents it is necessary to understand why they occur. This understanding is gained by utilising accident causation theory to explain why a certain combination of events, conditions and actions led to a given outcome: the process of accident analysis. At present, the systems approach to accident analysis is arguably the dominant research paradigm. Based on the concepts of systems theory, it views accidents as the result of unexpected and uncontrolled relationships between a system s components. Various researchers claim that use of the systems approach, via systemic accident analysis, provides a deeper understanding of accidents when compared with traditional theories. However, the systems approach and its analysis techniques are yet to be widely adopted by the practitioner community and, therefore, a research-practice gap exists. The implication of such a gap is that practitioners may be applying outdated accident causation theory and, consequently, producing ineffective safety recommendations. The aim of this thesis was to develop the current understanding of the systemic accident analysis research-practice gap by providing a description of the gap, considering its extent and examining issues associated with bridging it. Four studies were conducted to achieve this aim. The first study involved an evaluation of the systemic accident analysis literature and techniques, in order to understand how their characteristics could influence the research-practice gap. The findings of the study revealed that the systems approach is not presented in a consistent or clear manner within the research literature and that this may hinder its acceptance by practitioners. In addition, a number of issues were identified (e.g. model validation, analyst bias and limited usage guidance) which may influence the use of systemic analysis methods within industry. The examination of how the analysis activities of practitioners may contribute to the gap motivated Study 2. This study involved conducting semi-structured interviews with 42 safety professionals and various factors, which affect the awareness, adoption and usage of the systems approach and its analysis methods, were highlighted. The combined findings of Studies 1 and 2 demonstrate that the systemic accident analysis research-practice gap is multifaceted in nature. Study 3 investigated the extent of the gap by considering whether the most widely used analysis technique (the Swiss Cheese Model) can provide a systems approach to accident analysis. The analysis of a major rail accident was performed with a model based on the Swiss Cheese Model and two systemic analysis methods. The outputs and usage of the three analysis tools were compared and indicate that the Swiss Cheese Model does provide a means of conducting systemic accident analysis. Therefore, the extent of the research-practice gap may not be as considerable as some proponents of the systems approach suggest. The final study aimed to gain an insight into the application of a systemic accident analysis method by practitioners, in order to understand whether it meets their needs. Six trainee accident investigators took part in an accident investigation simulation and subsequently analysed the data collected during the exercise with the Systems Theoretic Accident Modelling and Processes model. The outputs of the participants analyses were studied along with the evaluation feedback they provided via a questionnaire and focus group. The main findings of the study indicate that the analysis technique does not currently meet the usability or graphical output requirements of practitioners and, unless these issues are addressed, will struggle to gain acceptance within industry. When considering the research findings as a whole a number of issues are highlighted. Firstly, given the benefits of adopting the systems approach, efforts to bridge the systemic accident analysis research-practice gap should be made. However, the systemic analysis methods may not be best suited to analyse every type of accident and, therefore, should be considered as one part of an investigator s analysis toolkit . Adapting the systemic analysis methods to meet the needs of practitioners and communicating the systems approach more effectively represent two options for bridging the gap. However, due to the multidimensional nature of the gap and the wide variety of individuals, organisations and industries that perform accident analysis, it seems likely that tailored solutions will be required. Furthermore, due to the differing needs of the research and practice communities, efforts to bridge the gap should focus on collaboration between the two communities rather than attempting to close the gap entirely.