At the time I wrote this I was working with various methods to investigate accidents. I have since found that Leveson’s STAMP provides the most robust method. This paper may be useful in a technique to help the field investigator focus on the context of why a person did what they did, but after that I believe STAMP should be applied. The abstract follows:
This paper proposes that the concepts developed for Just Culture may provide an avenue to broaden the scope of accident investigation and move away from the “blame” outcome of most reports through the use of a simple Just Culture algorithm to mitigate cognitive bias on the part of the investigator. Absent a formal strategy, cognitive bias has a high probability of occurring, and becoming integrated into the investigators subconscious during the early stages of an accident investigation. Just Culture is becoming widely accepted, and as such the transition to integrating an investigative model utilizing the concept should be easier to implement and may encounter less political push back than some of the more complex approaches proposed in recent years, yet still provide a robust path to causality and human factors aspects that is more comprehensive than that offered through the traditional models that are still in use by most organizations.