Practical Methods for Accident Investigation

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In my previous article I posted a link to a paper I had written originally in 2014 and presented at a conference for the South East Regional meeting of ISASI.  The topic of investigations came up last Spring when I attended the Resilience Engineering Association meeting in Liege.  I expressed that part of the issue we should address is that the investigations themselves may be tainted and that I had written a paper regarding this.  The result was that I was asked if I would like to present it as they had a cancellation, so I found my old presentation and did so.

I continue to be concerned about the early stages of investigations.  I have spent enough time as part of the investigative team to see that an investigation can be overly impacted by first impressions.  That still leaves how to best gain the most knowledge and recommendations out of an accident investigation.  As I wrote in my last post, after spending more time with the methods, I have found that the STAMP method is the most practical to apply.  As I  also stated in the paper, though, STAMP does require training.  Unlike just culture, which is very easy to explain (the concepts understood inside of 15 minutes by most practitioners), one really has to sit down and work through it a few times to understand it, and, furthermore, it is only after doing so that one can see how it really outshines the other methods.  There are workshops available, and the material is available for free on the MIT website, but, at least for me, just reading the material did not do the trick.  Perhaps this is part of why there has been resistance in some quarters to it — it requires some cognitive work to understand it.

Over the past few months I have had an opportunity to do a lot more, and while previously I just saw the potential, now I am a believer.  After returning from Liege I got to work in earnest to prepare an analysis of the Asiana 214 accident for the ISASI annual seminar.  Up to that point, while we had planned to do it, most of the work consisted of just collecting the data and discussions.  I had read about how it yielded more findings and recommendations than other methods, and I believed that to be true, but I had not personally worked a new problem myself.  There was always the lurking thought in my mind that perhaps the additional results were just the outcome of being able to go through an accident again with the benefit of both the report and additional time and research, and not due to a particular method.  However, with MIT research professor, John Thomas, Ph.D., I was able to really apply the STAMP method.  The result was a presentation and paper, which was very well received (you can download it here: Learning from Accidents that are a Consequence of Complex Systems .  It was at that point that the power of STAMP truly became “real” for me.  I had thought I understood it before that, but I really had not fully grasped it.  There is no question in my mind now that STAMP yields far more than would be possible absent the application of the methods.  No question.

As you can see, I am now a strong advocate of STAMP and I believe it can be applied to many problems outside of just safety investigations.   I believe it provides a practical application that is not present in FRAM (at least not that I have been able to figure out).  HFACs just leads to classifying “error” and is the entirely wrong track, in my opinion, and HFIX does little to improve it.  I know they are popular.  Sorry.

There still remains the problem of the early stages of investigations and training investigators to use it when in the field, but that is not insurmountable.  It is a training problem, and perhaps a toolkit can be developed to aid in this area.  So with that, if you are not familiar with STAMP, I suggest you start some reading.   Stay tuned for more!

Footnotes:

STAMP is System Theoretic Accident Models and Processes. 

See also: http://stamp-consulting.com

FRAM is Functional Resonance Accident Model 

HFACs is the Human Factors Analysis and Classification System.

 

 

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About Shem Malmquist FRAeS

B-777 Captain. Air Safety and Accident Investigator. Previous experience includes Flight Operations Duty Officer, Assistant Chief Pilot. Line Check Airman, ALPA Aircraft Technical and Engineering Chairman, Aircraft Performance and Designs Committee MEC Chair, Charting and Instrument Procedures Committee, Group Leader-Commercial Aviation Safety Team-Joint Safety Implementation Team (CAST)-Loss of Control-Human Factors and Automation, CAST-JSIT- Aircraft State Awareness. Fellow of the Royal Aeronautical Society, full Member of ISASI, AIAA, IEEE, HFES, FSF, AFA and the Resilience Engineering Association.
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