What you find is not always what you fix--how other aspects than causes of accidents decide recommendations for remedial actions

Risk Controls Identified in Action Plans Following Serious Incident Investigations in Secondary Care: A Qualitative Study

OBJECTIVES

The impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. We aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterize the nature of the risk controls proposed.

METHODS

We undertook a content analysis of 126 action plans of serious incident investigation reports from a multisite and multispeciality UK hospital over a 3-year period to identify the risk controls proposed. We coded each risk control against the contributory factor it aimed to address. Using a hierarchy of risk controls model, we assessed the strength of proposed risk controls. We used thematic analysis to characterize the nature of proposed risk controls.

RESULTS

A substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls. Of the 822 proposed risk controls in action plans, most (74%) were assessed as weak, typically focusing on individualized interventions-even when the problems were organizational or systemic in character. The following 6 broad approaches to risk controls could be identified: improving individual or team performance; defining, standardizing, or reinforcing expected practice; improving the working environment; improving communication; process improvements; and disciplinary actions.

CONCLUSIONS

The identified shortfalls in the quality of risk controls following serious incident investigations-including a 15% mismatch between contributory factors and aligned risk controls and 74% of proposed risk controls centering on weaker interventions-represent significant gaps in translating incident investigations into meaningful systemic improvements. Advancing the quality of risk controls after serious incident investigations will require involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning, all supported by a common framework.

Improving Remedial Measures from Incident Investigations: A Study Across Ghanaian Mines

Background

Learning from incidents for accident prevention is a two-stage process, involving the investigation of past accidents to identify the causal factors, followed by the identification and implementation of remedial measures to address the identified causal factors. The focus of past research has been on the identification of causal factors, with limited focus on the identification and implementation of remedial measures. This research begins to contribute to this gap. The motivation for the research is twofold. First, previous analyses show the recurring nature of accidents within the Ghanaian mining industry, and the causal factors also remain the same. This raises questions on the nature and effectiveness of remedial measures identified to address the causes of past accidents. Secondly, without identifying and implementing remedial measures, the full benefits of accident investigations will not be achieved. Hence, this study aims to assess the nature of remedial measures proposed to address investigation causal factors.

Method

The study adopted SMARTER from business studies with the addition of HMW (H - Hierarchical, M - Mapping, and W - Weighting of causal factors) to analyse the recommendations from 500 individual investigation reports across seven different mines in Ghana.

Results

The individual and the work environment (79%) were mostly the focused during the search for causes, with limited focus on organisational factors (21%). Forty eight percentage of the recommendations were administrative, focussing on fixing the problem in the immediate affected area or department of the victim(s). Most recommendations (70.4%) were support activities that only enhance the effectiveness of control but do not prevent/mitigate the failure directly. Across all the mines, there was no focus on evaluating the performance of remedial measures after their implementation.

Conclusion

Identifying sharp-end causes leads to proposing weak recommendations which fail to address latent organisational conditions. The study proposed a guide for effective planning and implementation of remedial actions.

Conceptualising learning from resilient performance: A scoping literature review

Resilient performance is a crucial characteristic of complex socio-technical systems, enabling them to sustain essential functionality during changing or stressful conditions. Resilience Engineering (RE), a sub-field of safety research, focuses on this perspective of resilience. RE emphasises its "cornerstone model", presenting the RE system goals of "anticipating, monitoring, responding and learning". The cornerstone of learning remains fragmented and undertheorized in the existing literature. This paper aims to enrich RE research and its practical implications by developing a nuanced and comprehensive understanding of the role of learning from resilient performance. To achieve this aim, a scoping literature review was conducted to assess how learning is conceptualised in the RE literature and the theoretical foundations on which previous work rest. The main findings show that RE researchers view learning as the process of understanding the system, sharing knowledge, and re-designing system properties. The application of established learning theories is limited. This paper contributes to research by proposing an organisational process for the RE cornerstone of learning, paving the way for deeper discussions in future studies about learning from resilient performance within complex socio-technical systems.

Exploring the "Black Box" of Recommendation Generation in Local Health Care Incident Investigations: A Scoping Review

BACKGROUND

Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. There is little empirical evidence about how-in real-world hospital settings-recommendations are generated or judged for effectiveness.

OBJECTIVES

Our research questions, concerning internal hospital investigations, were as follows: (1) What approaches to incident investigation are used before the generation of recommendations? (2) What are the processes for generating recommendations after a patient safety incident investigation? (3) What are the number and types of recommendations proposed? (4) What criteria are used, by hospitals or study authors, to assess the quality or strength of recommendations made?

METHODS

Following PRISMA-ScR guidelines, we conducted a scoping review. Studies were included if they reported data from investigations undertaken and recommendations generated within hospitals. Review questions were answered with content analysis, and extracted recommendations were categorized and counted.

RESULTS

Eleven studies met the inclusion criteria. Root cause analysis was the dominant investigation approach, but methods for recommendation generation were unclear. A total of 4579 recommendations were extracted, largely focusing on individuals' behavior rather than addressing deficiencies in systems (<7% classified as strong). Included studies reported recommendation effectiveness as judged against predefined "action" hierarchies or by incident recurrence, which was not comprehensively reported.

CONCLUSIONS

Despite the ubiquity of incident investigation, there is a surprising lack of evidence concerning how recommendation generation is or should be undertaken. Little evidence is presented to show that investigations or recommendations result in improved care quality or safety. We contend that, although incident investigations remain foundational to patient safety, more enquiry is needed about how this important work is actually achieved and whether it can contribute to improving quality of care.

Cognitive bias in workplace investigation: Problems, perspectives and proposed solutions

Psychological research demonstrates how our perceptions and cognitions are affected by context, motivation, expectation, and experience. A mounting body of research has revealed the many sources of bias that affect the judgments of experts as they execute their work. Professionals in such fields as forensic science, intelligence analysis, criminal investigation, medical and judicial decision-making find themselves at an inflection point where past professional practices are being questioned and new approaches developed. Workplace investigation is a professional domain that is in many ways analogous to the aforementioned decision-making environments. Yet, workplace investigation is also unique, as the sources, magnitude, and direction of bias are specific to workplace environments. The workplace investigation literature does not comprehensively address the many ways that the workings of honest investigators' minds may be biased when collecting evidence and/or rendering judgments; nor does the literature offer a set of strategies to address such happenings. The current paper is the first to offer a comprehensive overview of the important issue of cognitive bias in workplace investigation. In it I discuss the abilities and limitations of human cognition, provide a framework of sources of bias, as well as, offer suggestions for bias mitigation in the investigation process.

Humanizing harm: Using a restorative approach to heal and learn from adverse events

Background

Healthcare is not without risk. Despite two decades of policy focus and improvement efforts, the global incidence of harm remains stubbornly persistent, with estimates suggesting that 10% of hospital patients are affected by adverse events.

Methods

We explore how current investigative responses can compound the harm for all those affected—patients, families, health professionals and organizations—by neglecting to appreciate and respond to the human impacts. We suggest that the risk of compounded harm may be reduced when investigations respond to the need for healing alongside system learning, with the former having been consistently neglected.

Discussion

We argue that incident responses must be conceived within a relational as well as a regulatory framework, and that this—a restorative approach—has the potential to radically shift the focus, conduct and outcomes of investigative processes.

Conclusion

The identification of the preconditions and mechanisms that enable the success of restorative approaches in global health systems and legal contexts is required if their demonstrated potential is to be realized on a larger scale. The policy must be co‐created by all those who will be affected by reforms and be guided by restorative principles.

Patient or Public Contribution

This viewpoint represents an international collaboration between a clinician academic, safety scientist and harmed patient and family members. The paper incorporates key findings and definitions from New Zealand's restorative response to surgical mesh harm, which was co‐designed with patient advocates, academics and clinicians.

Impact of an Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis of Adverse Events in Health Care Facilities: Results of a Randomized Controlled Trial

OBJECTIVE

The aim of the study was to assess the effectiveness of a new methodological tool for the identification of corrective and preventive actions (CAPAs) after root cause analysis of health care-related adverse events.

METHODS

From January to June 2010, we conducted a randomized controlled trial involving risk managers from 111 health care facilities of the Aquitaine Regional Center for Quality and Safety in Health Care (France). Fifty-six risk managers, randomly assigned to two groups (intervention and control), identified CAPAs in response to two sequentially presented adverse event scenarios. For the baseline measure, both groups used their usual adverse event management tools to identify CAPAs in each scenario. For the experimental measure, the control group continued using their usual tools, whereas the intervention group used a new tool involving a systemic approach for CAPA identification. The main outcome measure was the number of CAPAs the participants identified that matched a criterion standard established by eight experts.

RESULTS

Baseline mean number of identified CAPAs did not differ between the two groups (P = 0.83). For the experimental measure, significantly more CAPAs (P = 0.001) were identified by the intervention group (mean [SD] = 4.6 [1.7]) than by the control group (mean [SD] = 2.8 [1.2]).

CONCLUSIONS

For the two scenarios tested, more relevant CAPAs were identified with the new tool than with usual tools. Further research is needed to assess the effectiveness of the new tool for other types of adverse events and its impact on patient safety.

Safety-II and Resilience Engineering in a Nutshell: An Introductory Guide to Their Concepts and Methods

Background

Traditional safety concept, which is called Safety-I, and its relevant methods and models have much contributed toward enhancing the safety of industrial systems. However, they have proved insufficient to be applied to complex socio-technical systems. As an alternative, Safety-II and resilience engineering have emerged and gained much attention for the last two decades. However, it seems that safety professionals have still difficulty understanding their fundamental concepts and methods. Accordingly, it is necessary to offer an introductory guide to them that helps safety professionals grasp them correctly in consideration of their current practices.

Methods

This article firstly explains the limitations of Safety-I and how Safety-II can resolve them from the four points of view. Next, the core concepts of resilience engineering and Functional Resonance Analysis Method are described.

Results

Workers' performance adjustment and performance variability due to it should be the basis for understanding human-related accidents in socio-technical systems. It should be acknowledged that successful and failed work performance have the same causes. However, they are not well considered in the traditional safety concept; in contrast, Safety-II and resilience engineering have conceptual bases and practical approaches to reflect them systematically.

Conclusion

It is necessary to move from a find-and-fix and reactive approach to a proactive approach to safety management. Safety-II and resilience engineering give a set of useful concepts and methods for proactive safety management. However, if necessary, Safety-I methods need to be properly used for situations where they can still be useful as well.

Identification of factors that influence occupational accidents in the petroleum industry: A qualitative approach

BACKGROUND

Exploring experiences of individuals for barriers they confront relating to safety could help to design safety interventions with an emphasis on the most safety influencing factors.

OBJECTIVE

This study strived to present an empirical exploration of individuals' experiences across the petroleum industry at different levels of the organizational structure for factors that influence occupational accidents.

METHOD

Based on accidents history, face-to-face semi-structured interviews were conducted with individuals who engaged in fatal activities, as well as authorities responsible for managing safety. The qualitative content analysis of 46 interview transcripts was conducted using MAXQDA software.

RESULTS

A three-layer model comprising organizational, supervisory and operator level influencing factors with 16 categories were found influence factors of occupational safety. The results highlighted the role of organizational factors, including inappropriate contract management, inadequate procedures, and issues relating to competency management and the organizational climate. Moreover, defects relating to the monitoring and supervision system were identified as important causes of accidents.

CONCLUSIONS

The findings demonstrated that the qualitative approach could reveal additional latent aspects of safety influencing factors, which require consideration for the appropriate management of occupational safety. This study can guide the planning of preventive strategies for occupational accidents in the petroleum industry.

Applying AcciMap to test the common cause hypothesis using aviation near misses

The common cause hypothesis, as applied here, proposes that similar networks of influencing factors may contribute to both adverse outcomes and near misses. This hypothesis has not been evaluated using a systems-thinking perspective. The aims of this study are to evaluate whether networks of contributory and protective factors exist within aviation serious near miss reports and to determine if the common cause hypothesis is applicable in this context. Sixteen incident reports from French civil aviation crash investigation bureau were analysed using the AcciMap method. Contributory and protective factors, and relationships between both were identified via coding of the reports. The results indicate that considering protective factors support a richer picture of incidents and provide support for the common cause hypothesis as measured by similar mean factor volume and sociotechnical levels for both contributory and protective factors. However, the findings also show the direction of relationships among protective and contributory factors may be indicative of a difference among adverse outcomes, near misses, and normal work. Future research should consider how a network of relationships may impact on the common contributory and protective factors found in near misses.

Pre-hospital triage performance and emergency medical services nurse's field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study

BACKGROUND

In Sweden, the rapid emergency triage and treatment system (RETTS-A) is used in the pre-hospital setting. With RETTS-A, patients triaged to the lowest level could safely be referred to a lower level of care. The national early warning score (NEWS) has also shown promising results internationally. However, a knowledge gap in optimal triage in the pre-hospital setting persists. This study aimed to evaluate RETTS-A performance, compare RETTS-A with NEWS and NEWS 2, and evaluate the emergency medical service (EMS) nurse's field assessment with the physician's final hospital diagnosis.

METHODS

A prospective, observational study including patients (≥16 years old) transported to hospital by the Gothenburg EMS in 2016. Three comparisons were made: 1) Combined RETTS-A levels orange and red (high acuity) compared to a predefined reference emergency, 2) RETTS-A high acuity compared to NEWS and NEWS 2 score ≥ 5, and 3) Classification of pre-hospital nurse's field assessment compared to hospital physician's diagnosis. Outcomes of the time-sensitive conditions, mortality and hospitalisation were examined. The statistical tests included Mann-Whitney U test and Fisher's exact test, and several binary classification tests were determined.

RESULTS

Overall, 4465 patients were included (median age 69 years; 52% women). High acuity RETTS-A triage showed a sensitivity of 81% in prediction of the reference patient with a specificity of 64%. Sensitivity in detecting a time-sensitive condition was highest with RETTS-A (73%), compared with NEWS (37%) and NEWS 2 (35%), and specificity was highest with NEWS 2 (83%) when compared with RETTS-A (54%). The negative predictive value was higher in RETTS-A (94%) compared to NEWS (91%) and NEWS 2 (92%). Eleven per cent of the final diagnoses were classified as time-sensitive while the nurse's field assessment was appropriate in 84% of these cases.

CONCLUSIONS

In the pre-hospital triage of EMS patients, RETTS-A showed sensitivity that was twice as high as that of both NEWS and NEWS 2 in detecting time-sensitive conditions, at the expense of lower specificity. However, the proportion of correctly classified low risk triaged patients (green/yellow) was higher in RETTS-A. The nurse's field assessment of time-sensitive conditions was appropriate in the majority of cases.

Investigating the Maturity of Incident Investigations of the Ghanaian Mining Industry and Its Effect on Safety Performance

Effective incident investigations have been recognised as a vital means of improving safety. Nevertheless, there has been little attempt to link incident investigations to actual safety performance. In this study, a framework for assessing the maturity of incident investigations and identifying areas for improvements is described. The framework was developed based on a literature review and interviews with 41 investigators across five large-scale Ghanaian gold mines. The framework consists of 20 elements across four dimensions and five maturity levels. The dimensions (investigator competencies, system of investigation, stages of investigation and post-investigation findings) consider the most relevant aspects of practical investigation and for each dimension, elements that are more specific were defined across five maturity levels. Mapping the interview data collected from five mines into a maturity framework highlighted that the mines occupied different positions on the framework. Some occupied the advanced levels consistently and others consistently occupied the lower levels. Applying the interview data to the framework also identified priority areas for improvement. Finally, the maturity scores derived from mapping interview data onto the framework were correlated with the incidence rates of the mines to determine if any relationship existed between the two variables. The low incidence rate mines had higher maturity scores and the high incidence rate mines had lower maturity scores. It was found that the method was effective in practice, giving clear indications of areas where improvements are needed.

Integrating systemic accident analysis into patient safety incident investigation practices

There is growing awareness of the limitations of current practice regarding the investigation of patient safety incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error incident. The STAMP analysis was undertaken by two HFE researchers with the participation of twenty-one healthcare stakeholders. The STAMP-based approach guided healthcare stakeholders towards consideration of system design issues and remedial actions, going beyond the individual-based remedial actions proposed by the RCA. The study offers insights into how HFE can be integrated into current practice.

Qualitative ergonomics/human factors research in health care: Current state and future directions

The objective of this systematic review was to understand the current state of Ergonomics/Human Factors (E/HF) qualitative research in health care and to draw implications for future efforts. This systematic review identified 98 qualitative research papers published between January 2005 and August 2015 in the seven journals endorsed by the International Ergonomics Association with an impact factor over 1.0. The majority of the studies were conducted in hospitals and outpatient clinics, were focused on the work of formal health care professionals, and were classified as cognitive or organizational ergonomics. Interviews, focus groups, and observations were the most prevalent forms of data collection. Triangulation and data archiving were the dominant approaches to ensuring rigor. Few studies employed a formal approach to qualitative inquiry. Significant opportunities remain to enhance the use of qualitative research to advance systems thinking within health care.

Rasmussen's legacy in the great outdoors: A new incident reporting and learning system for led outdoor activities

Jens Rasmussen's seminal risk management framework and accompanying Accimap method have become highly popular in safety science circles. Despite this, widespread adoption of the model and method in practice has not yet been achieved. This paper describes a project involving the development and implementation of an incident reporting and learning system underpinned by Rasmussen's risk management framework and Accimap method. The system was developed for the led outdoor activity sector in Australia to enable reporting and analysis of injuries and near miss incidents, with the aim of supporting the development of more effective countermeasures. An analysis of the data derived from the first 3 months use of the system by 43 organisations is presented. The outputs provide an in-depth Accimap-based analysis of all incidents reported by participating organisations over the 3 month period. In closing, the importance of developing usable domain specific tools to support translation of Ergonomics theory and methods in practice is discussed.

Beyond human error taxonomies in assessment of risk in sociotechnical systems: a new paradigm with the EAST 'broken-links' approach

Risk assessments in Sociotechnical Systems (STS) tend to be based on error taxonomies, yet the term 'human error' does not sit easily with STS theories and concepts. A new break-link approach was proposed as an alternative risk assessment paradigm to reveal the effect of information communication failures between agents and tasks on the entire STS. A case study of the training of a Royal Navy crew detecting a low flying Hawk (simulating a sea-skimming missile) is presented using EAST to model the Hawk-Frigate STS in terms of social, information and task networks. By breaking 19 social links and 12 task links, 137 potential risks were identified. Discoveries included revealing the effect of risk moving around the system; reducing the risks to the Hawk increased the risks to the Frigate. Future research should examine the effects of compounded information communication failures on STS performance. Practitioner Summary: The paper presents a step-by-step walk-through of EAST to show how it can be used for risk assessment in sociotechnical systems. The 'broken-links' method takes a systemic, rather than taxonomic, approach to identify information communication failures in social and task networks.

Failing to Fix What is Found: Risk Accommodation in the Oil and Gas Industry

The present program of research synthesizes the findings from three studies in line with two goals. First, the present research explores how the oil and gas industry is performing at risk mitigation in terms of finding and fixing errors when they occur. Second, the present research explores what factors in the work environment relate to a risk-accommodating environment. Study 1 presents a descriptive evaluation of high-consequence incidents at 34 oil and gas companies over a 12-month period (N = 873), especially in terms of those companies' effectiveness at investigating and fixing errors. The analysis found that most investigations were fair in terms of quality (mean = 75.50%), with a smaller proportion that were weak (mean = 11.40%) or strong (mean = 13.24%). Furthermore, most companies took at least one corrective action for high-consequence incidents, but few of these corrective actions were confirmed as having been completed (mean = 13.77%). In fact, most corrective actions were secondary interim administrative controls (e.g., having a safety meeting) rather than fair or strong controls (e.g., training, engineering elimination). Study 2a found that several environmental factors explain the 56.41% variance in safety, including management's disengagement from safety concerns, finding and fixing errors, safety management system effectiveness, training, employee safety, procedures, and a production-over-safety culture. Qualitative results from Study 2b suggest that a compliance-based culture of adhering to liability concerns, out-group blame, and a production-over-safety orientation may all impede safety effectiveness.

Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the “broken components.” However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system.

Mind the gap between recommendation and implementation-principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations

OBJECTIVES

Using the findings of incident investigations to improve patient safety management is well-established and mandatory under Swedish law. This study seeks to identify the mechanisms behind successful implementation of the recommendations of incident investigations.

SETTING

This study was based in a university hospital in southern Sweden.

PARTICIPANTS

A sample of 55 incident investigations from 2008 to 2010 were selected from the hospital's incident reporting system by staff in the office of the chief medical officer. These investigations were initiated by 23 different commissioning bodies and contained 289 separate recommendations. We used a three-stage method: content analysis to code the recommendations, semi-structured interviews with the commissioning bodies focusing on which recommendations had been implemented and why, and data analysis of the coded recommendations together with data from the interviews.

RESULTS

We found that a clear majority (70%) of the recommendations presented to the commissioning bodies were targeted at the micro-level of the organisation. In nearly half (45%) of all recommendations, actions had been taken and a clear majority (73%) of these were at the micro-level. Changes in the management positions of the commissioning bodies meant that very little further action was taken. Other actions, independent of incident investigations, were often taken within the organisation.

CONCLUSIONS

We conclude that two principles ('close in space' and 'close in time') seem to be important for bridging the gap between recommendation and implementation. The micro-level focus was expected because of the method of investigation used. Adverse events trigger organisational action independently of incident investigations.

Human and organisational factors in maritime accidents: analysis of collisions at sea using the HFACS

Over the last decade, the shipping industry has implemented a number of measures aimed at improving its safety level (such as new regulations or new forms of team training). Despite this evolution, shipping accidents, and particularly collisions, remain a major concern. This paper presents a modified version of the Human Factors Analysis and Classification System, which has been adapted to the maritime context and used to analyse human and organisational factors in collisions reported by the Marine Accident and Investigation Branch (UK) and the Transportation Safety Board (Canada). The analysis shows that most collisions are due to decision errors. At the precondition level, it highlights the importance of the following factors: poor visibility and misuse of instruments (environmental factors), loss of situation awareness or deficit of attention (conditions of operators), deficits in inter-ship communications or Bridge Resource Management (personnel factors). At the leadership level, the analysis reveals the frequent planning of inappropriate operations and non-compliance with the Safety Management System (SMS). The Multiple Accident Analysis provides an important finding concerning three classes of accidents. Inter-ship communications problems and Bridge Resource Management deficiencies are closely linked to collisions occurring in restricted waters and involving pilot-carrying vessels. Another class of collisions is associated with situations of poor visibility, in open sea, and shows deficiencies at every level of the socio-technical system (technical environment, condition of operators, leadership level, and organisational level). The third class is characterised by non-compliance with the SMS. This study shows the importance of Bridge Resource Management for situations of navigation with a pilot on board in restricted waters. It also points out the necessity to investigate, for situations of navigation in open sea, the masters' decisions in critical conditions as well as the causes of non-compliance with SMS.

Systemic accident analysis: examining the gap between research and practice

The systems approach is arguably the dominant concept within accident analysis research. Viewing accidents as a result of uncontrolled system interactions, it forms the theoretical basis of various systemic accident analysis (SAA) models and methods. Despite the proposed benefits of SAA, such as an improved description of accident causation, evidence within the scientific literature suggests that these techniques are not being used in practice and that a research-practice gap exists. The aim of this study was to explore the issues stemming from research and practice which could hinder the awareness, adoption and usage of SAA. To achieve this, semi-structured interviews were conducted with 42 safety experts from ten countries and a variety of industries, including rail, aviation and maritime. This study suggests that the research-practice gap should be closed and efforts to bridge the gap should focus on ensuring that systemic methods meet the needs of practitioners and improving the communication of SAA research.

Implementing recommendations from accident investigations: a case study of inter-organisational challenges

In many industries, a national accident investigation board conducts investigations following major accidents. For safety improvements to be achieved, however, it is essential that the recommendations presented in these investigations are followed by necessary actions. In this paper, challenges related to implementation of recommendations from accident investigations are studied. The theoretical framework providing the foundation for the study lies at the intersection between systems safety, risk governance, and implementation research. Empirical data for the case study was collected from the Swedish railway sector. The first part of the paper presents an analysis of the extent of recommendations that have not resulted in implemented actions. The second part consists of an interview study aiming at providing a deeper understanding of the difficulties related to transforming these recommendations into actual changes. Two key factors that give rise to challenges to implementation of recommendations are identified. The first factor is related to the different actors' views on their own and other stakeholders' roles in the implementation process, and can be described as a trade-off between being insider and outsider to the industry. The second factor is related to the scope of the accident investigations and their recommendations, and can be described as a trade-off between micro-level and macro-level factors. The opportunities for implementing recommendations, and achieving safety improvements at the industry level, are affected by the ways in which the different stakeholders manage these trade-offs at the local level. This study thus mainly contributes by highlighting the importance of co-ordinating the various actors involved in the implementation process, and the results show that challenges to implementation to a large extent arise in the interactions between these actors.

Strategies for dealing with resistance to recommendations from accident investigations

Accident investigation reports usually lead to a set of recommendations for change. These recommendations are, however, sometimes resisted for reasons such as various aspects of ethics and power. When accident investigators are aware of this, they use several strategies to overcome the resistance. This paper describes strategies for dealing with four different types of resistance to change. The strategies were derived from qualitative analysis of 25 interviews with Swedish accident investigators from seven application domains. The main contribution of the paper is a better understanding of effective strategies for achieving change associated with accident investigation.