Reported observed ambivalence about concern for safety; need for generalized accident theory; and risk -introducing risk /bearing/acceptance relationships in "Safety, Risk and Regulation" 1972
Reported observation that regulatory special permits enable safety experimentation on the public; cited observed hazmat risk variance along transport routes in "Hazardous Materials Transportation: Current And Future Issues" 1973
Observed and reported need for ability to predict hazmat behaviors during emergencies for improved emergency responder decision making in "Predicting Hazardous Materials Emergency Outcomes" 1975
Recognized need to research predicting hazmat behaviors in accidents and their control by chemical professionals in "Risk, Responsibility and Research" 1975
Based on synthesis of observed investigation practices, proposed multilinear process theory of accidents for investigators; method that produces compete, reproducible, conceptually consistent and easily communicated descriptions of accidents in "Accident Investigations: Multilinear Events Sequencing Methods" 1975
Based on insights gained by analysis of observations during investigations, proposed new emergency decision model for emergency responders; general hazmat emergency behavior model showing intervention points observed during investigations in "D.E.C.I.D.E. In Hazardous Materials Emergencies" 1975
Described need for accident theory to support investigation profession discovered during inquiries into theories underlying investigations in "Accident Theory And Accident Investigation" 1975
Book defined new paradigm for hazmat emergency response decision processes based on insights from observed behaviors during investigations in "Hazardous Material Emergencies" 1975
Proposed role of hypotheses in accident investigations to bridge gaps in scenarios observed during investigation in "Hypothesis Generation For Rare Events Research" 1976 Refined in 2013 ESReDA paper.
Observed and articulated five perceptions of accident phenomenon that influence investigations and research in "Accident Theories And Their Implications For Research" 1978
Developed and tested classroom simulations of accident investigation processes in "4 Accident Investigation Games" 1979
Using insights from observations and inquiries during investigations, identified 7 investigation processes, 44 reasons for investigations, 6 general methodologies and 3 investigation output types. in "Accident Investigations: A Case For New Perceptions And Methodologies" 1980
Observed and defined unaware investigator biases carried over from their academic disciplines; 6 categories of methodologies; and truth testing challenges observed during investigations in "Methodological Biases Which Undermine Accident Investigations" 1981
Based on observed needs, questions and responses during investigation interviews, developed and presented synthesized guidance to help investigators produce better understanding of human behaviors and their programming during investigations in "General Human Decision Process Model For Investigators1982
Based on observations of responder performance during investigations, presented synthesized method for evaluating emergency responses (Time/Loss Analysis method) in "Evaluating Hazmat Responses With Time/Loss Analysis" 1982
Described safety problem discovery and definition process problems observed while teaching investigation classes; Appendix listed 54 responses to Meaning of Cause in Accident Investigation?" to illustrate cause attribution problem in "Accident Models: How Underlying Differences Affect Workplace Safety" 1983
Reported observed lack use of investigation data feedback to update predictive safety analyses observed during accident investigations in "System Safety's Open Loops" 1983
Reported observed safety regulations' role as preempted safety decision in accident investigations; and implications for promulgating, training and compliance program formulation in "What Is This Thing Called A Safety Regulation?" 1984
During a system safety analysis project for an operational system, the significance of gaps and misrepresentations in the pre-existing documentation of the complex system operation was recognized during 6 successive updates required to achieve the complete and accurate description of the actual system operation needed for application of risk analysis tools; issue was detailed in the project report.
Devised and presented 30-element system for evaluating safety control selection based on observed needs during accident investigations and system safety analysis projects in "Corrective Action Evaluation" 1985
Updated 8 element model for investigating human decisions in accidents based on further investigation experiences in "Model Of Human Decision Process For Accident Investigators" 1992
Noted absence of criteria for rating and ranking accident models and investigation methodology then existent, and proposed criteria based on observations of investigation results and literature reviews in "Rating Accident Models and Investigation Methodologies" 1985
Based on observed problems with then current accident investigations, proposed new thinking about and approaches to investigations in book titled "Investigating Accidents With Step" 1986
Applied decision model developed from observations and interpretations of individual actions during accidents to pilot risk decision making, and reported experimental results in "The DECIDE Approach To Training Pilots In Pilot Decision Making" 1986
Analyzed and reported Identified reasons for observed controversy about proposed safety regulation and alternatives for reducing it in "Alternative Assessment Methods For Rail-Highway Grade Crossing Regulations" 1987
Based on observations of investigation reports and analyses, identified the detrimental role of abstractions as impediments to advancement in the understanding, prediction and control of safety problems in fields of human endeavor, and suggested remedy in "A Methodological Approach To The Search For Indirect (Human) Events Related To Mishaps" 1987
Described how gaps in reported accident descriptions adversely affect recommendation development and selection, and foiled replicability of investigations in "Fire Risks In The Carload And Truckload Transportation Of Class A Explosives" 1989
Based on challenges encountered and observations during accident investigation course development and presentations, described inadequate accident investigation support for investigator training programs in "Safety Training's Achilles' Heel" 1990
Based on observed logic flaws observed during investigations and in investigation reports, offered selected logic principles and relevance for accident investigators in "Logic And Logic Fallacies" 1990
Reported observed deficiencies in accident investigation recommendation process and potential application of system safety concepts in "Applying System Safety To The Safety Recommendation Process" 1991
Reported then current insights into problems with cause in investigations, and called on investigators to support changing it in "Guest Editorial: Problems With Cause" 1991
Reported the lack of quality management for accident investigations and their outputs observed during investigations, investigation report reviews and report follow-ups in "Quality Management For Accident Investigations (2 Parts)" 1992
Reported observed investigation recommendation development deficiencies and potential remedies. in "Ranking Safety Recommendation Effectiveness" 1992
Reported observed deficiencies in accident investigation data acquisition relevance, quality, quantity and accessibility, with remedial suggestions in "Paradigm Shifts To Exploit Successful Human Factors Interventions For Aircraft Accident Prevention" 1995
Recognized that words which had been observed to pose problems for investigations needed attention in " "Words Mean Something" 1995
Recognized need for and launched an open source on-line collection of documents and references to support investigation process researchers in "Investigation Process Research Resources Web Site" (www.iprr.org) 1996
Created Wish List for investigation researchers, based on issues identified during the conduct of investigations and analyses of investigation reports, issues identified during methods research or issues reported by others. Additions stopped about 2004 due to lack of outside interest.
Called attention to the need to integrate predictive System Safety analyses into accident investigations to assess their quality and efficacy in "Mishap Investigation tools for evaluating the quality of system safety program performance" 1996
Explored feasibility of collaboratively advancing investigation state of the art and defining investigation tasks using Internet. (Project abandoned in 1999) in "Experimental On-Line Investigation Research Project" 1997
Reported system safety analysis deficiencies with techniques and their requirements, observed during preparation of a system safety analysis project in "System Safety Analysis Pitfalls" 1997
Noted and reported the observed diversity of opinions about cause and causation in analysis of 14 ISASI seminar papers. in "Extracted Statements about cause taken from" 1996 ISASI Seminar Proceedings. 1998
Based on insights gained from observed differences in knowledge and skill demands observed during investigation processes, introduced crude idea of separating investigation from analysis functions, learning from episodic cases, glossary of terms for self reporting, etc. in "Preventing Flight Crew Errors: Primary Data Must Drive Analyses" 1998
Based on personal investigation experiences and observations, documented steps required to bring investigation plan to state of readiness for action as a Program Readiness Tree. in "Investigation Process planning Model" 1999
Summarizing observed task demands of accident investigators and tools used during investigations, presented task guidance for essential investigation functions, tasks and tools in "10 MES Investigation Guides" 1999
Reported investigation program design, planning and implementation steps based on personal investigation experiences and observations in "Investigation Programs chapter in Handbook of Industrial Automation" 2000
Utilized two different methodologies to investigate an accident, presenting results in "Investigating Investigation Methodologies" 2003
Conceived, set specifications for and managed development of software created to implement a computerized tool to enable investigators to produce rigorously disciplined graphical explanatory descriptions of accidental occurrences in "Investigation Catalyst software 2004-5
Documented examples of the adverse effects of the various forms of "did nots" observed in accident investigation reports in "Safety Improvement Should Be the Objective of Investigations" 2005
Exposed the unmet need for system safety professionals to continuously revalidate their work products with 10 examples in "Follow Through: It's Good For Golf; Its Great for System Safety" 2006
Analyzed and reported observed impediments to learning lessons from investigations, and options for overcoming them in "Accident Data for the Semantic Web" 2007
Called for system safety practitioners to have lessons learning system in place, etc in "Appraising "Lessons Learned" Practices" 2008
Described an analysis, based on insights from observed results of investigations and referenced criteria, and offered models for investigation lessons learning system for system safety analyses in "Lessons Learning System Attributes: An Analysis" 2009
Reported observed and analyzed needs for improving the investigation lessons learning process, proposed input/output framework in "Sifting Lessons from the Ashes: Avoiding Lost Learning Opportunities" 2009
Proposed standardizing investigation building blocks for reconstructing incident scenarios in nuclear industry, based on experiences with documentation and integration of observations during investigations in "Transforming Experience into Performance Improvement" 2010
Reported observed commonalities between accident investigations and crime scene reconstruction gleaned from dialogues with CSIs; also this cross-domain exploration resulted in first mention of safety investigations' frequently observed examples of their judicial constructs heritage in "Can Accident Investigation Tools Help Crime Scene Reconstruction" 2010
Described human tendency of reversion to old habits in emergencies first observed in emergency responders when investigating their losses during hazmat incidents and confirmed in recent aviation accidents in "Old habits die hard" 2010
Described observed challenges of average user's adaptation to increasingly complex new systems in "The Brave New World of Designers' Complexity" 2011
Developed and posted open source word processor-based tool for evaluating investigation report quality, in response to observed problems with using incident self-reporting system data in "Mishap Description Quality Analyzer" 2012
Recapitulating prior reports, proposed new investigation paradigm, standardized investigation input data and integration method in "Standardizing Safety Investigation Inputs to Reduce Risks" 2013
After observing problems created for accident analysts, researchers and other investigation data users due to diversity of investigation methods used, reported problems in "What to STAMP-based Analysts Expect of Safety Investigations" 2015
Summarized frequently observed but previously unappreciated significance of the effects of legal constructs on safety investigations during such investigations and investigation reports in "Is It Time To Purge Legal Constructs from Safety Investigations?" 2015
Created data base of >140 samples of different views of definitions of accident, investigation, investigation purpose, causation, causal statement requirements and human error from internet and personal library searches
- Updated 11 STEP-MES Investigation Guides to change reasoning requirements from causal to input/output reasoning, added rules and axioms for investigators, and other updates. (20180)
* List includes papers with coauthors: all are posted on the www.ludwigbenner.org web site.
This list of references contains information that illuminated the various perceptions of the accident phenomenon in my work during the period 1970 - 2013. They provided background information about accident research and thus were used to develop papers during that period. These references may be duplicated on subsequent lists. Some may no loger be accessible, although I have copies of many in my library.
Altman, J.W., Behavior and Accidents, Journal of Safety Research, 2:3,197O.
American National Standards Institute, U.S. Standard Method of Recording Basic Facts Relating to the Nature and Occurrence of Accidents, Pamphlet Z 18.2–1962, New York, NY, 1962.
American Society of Safety Engineers. Proceedings of the Professional Development Conference, Dallas TX AASW, 1973
Ames, J. S., First National Aeronautical Safety Conference, 17th Annual Safety Congress, National Safety Council Transactions, Chicago, IL, 1928.
Automotive Safety Foundation, Traffic Control & Roadway Elements–Their Relation to Highway Safety, Washington, DC, 1963.
Automotive Safety Foundation, A Fact-Gathering Guide to Assist States inDeveloping a Highway Safety Program, Washington, DC, 1968.
Baker, J.S., Traffic Accident Investigators Manual for Police, Northwestern>University, Evanston, IL, 1963. .
Baker, J.S., Problems of Determining Causes of Specific Accidents, Traffic Institute, Northwestern University, Evanston, IL, 1963.
Baker, J.S., and Ross, H.L., Concepts and Classification of Traffic Accident Causes, Traffic Institute, Northwestern University, Evanston, IL, 1960.
Baker, J. S, Traffic Accident Investigation Manual for Police, Evanston, Il, Northwestern University 1971
Baker, S.P., Injury Control, Preventative Medicine and Public Health, 10th Ed. App1eton–Century–Crofts, New York, NY, 1972.
Benner, L.Accident Investigations: Multilinear Events Sequencing Methods" Journal of Safety Research, Chicago , IL. National Safety Council, Vol 7, No. 2, p 57-73. 1975
Benner, L., Safety, Risk and Regulation, Transportation Research Forum Proceedings, 13:1, Chicago, IL, 1972.
Bird, Frank El, Jr. Management Guide to Loss Control, Atlanta. Institute Press , 1974
Blake, R.P., (Ed.) Industrial Safety, Prentice Hall, New York, NY, 1943.
Blumenthal, M., Dimensions of the Traffic Safety Problem, Traffic Safety Research Review, 12:7, 1966.
Blumenthal, M., An Alternative Approach to Measurement of Industrial Safety Performance Based on a Structured Concept of Accident Causation, Journal of Safety Research, 2:3,1970.
Blumenthal, M., Problem Definition: The Driving Task in the System Context, Behavioral Research in Highway Safety, 2:1, 1971.
Bornoff, L.H., The Human Side of Safety, The H. K Ferguson Co., Cleveland, Ohio, 1957.
Brody, L., Accidents and Attitudes, Center for Safety Education, New York University, New York:, NY 1958
Brody, L., The Accident Phenomenon, Personnel Administration, 26:6,1963.
Buehler, J.H., et al, Report on Explosion at Union Carbide’s Texas City Butadiene Refining Unit, Chemical Engineering, September 7,1970.
Bulloch, B.C., The Practical Application of’ Reliability Engineering Techniques to Chemical P1ant Safety, ICI Ltd., Cheshire., Eng1and, 1974.
Calabresi, G., The Costs of’ Accidents, Yale University Press, New Haven CT,1970.
Canadian Forces Headquarters, Flight Safety for the Canadian Forces, Ottawa: Department of National Defence, 1971.
___Code of’ Federal Regulations, tithe 49, Subtitle B 1–VI, Government Printing Office, Washington, DC, 1974.
Collins, James C. and Morris, Joe L. Highway Collision Analysis, Springfield,. Ill. Charles C, Thomas, 1974.
Coppin, R.S., and Peck, R.C., The Development and Evaluation of Accident Countermeasures in Driver Licensing, Proceedings of SAE/DOT International Vehicle and Highway Safety Conference, Washington, DC, 1972.
Cutter, W.A., You and Automotive Traffic, Driver Education and Traffic Safety, Prentice Ha11, Inc. Englewood Cliffs, N.J, 1967.
Driessen, G.J., Cause Tree Analysis, Measuring how Accidents Happen and the Probabilities of Their Cause, presentation to American Psychological Association, September, 1970.
Ehrlich , S.G. and Jones , Leland V. Photographic Evidence: The Preparation and Use of Photographs in Civil and Criminal Cases, London, Maclaren & Sons, 1967.
Fault Tree for Safety, D 6–75133, The Boeing Company Seattle, WA, 1965.
Ferry, Ted S. ed. Human Factors in Aircraft Accident Investigation Second Annual Seminar_SASI . Los Angeles :University of Southern California, 1971.
Ferry, Ted S. Multidisciplinary References for Aircraft Accident Investigation, Arlington, VA: Flight Safety Foundation, 1975.
Fawcett, H.H., and Wood, W. S., (Ed.) Safety and Accident Prevention in Chemical Operations, John Wiley & Sons, New York, NY, 1965.
Fine, W.T. , Mathematical Evaluation for Controlling Hazards, Journal of Safety Research, 3:4, 1971.
Garrick, B. J., et al, A Risk Model for the Transport of Hazardous Materials, Holmes and Narver, Inc., Los Angeles, CA, 1969.
Gazis, D.C. ,Traffic and Control Theory and applications, American Scientist, Vol. 60, 1972.
Gibson, J. J., The Contribution of’ Experimental Psychology to the Formulation of’ the Problems of Safety; A Brief for Basic Research, Behavioral Approaches to Accident Research, Association for the Aid of Crippled Children, New York, NY , 1960.
Gibson, R., (Ed.) The Safe Transportation of Radioactive Materials, Pergamon Press, London, England.1966
Goeller, B F. , Modeling the Traffic Safety System, Accident Analysis and Prevention, Vol. 1, 1969.
Graves, K.W. , Fire Fighter’s s Exposure Study , Technical Report ACFSRS 71–2, Air Force Systems Program Office, Wright Patterson Air Force Base, Ohio, December, 1970.
Grose, V.L. , System Safety in Rapid Rail Transit Proceedings AS./NRC conference on Hazard Evaluation arid Risk Analysis, Houston TX , 1971.
Haddon, W.Jr., The Prevention of Accidents, Preventative Medicine, Little Brown and Co., Boston , MA, 1967.
Haddon, W. Jr., The Changing Approach to the Epidemiology, Prevention and Amelioration of Trauma; The transition to Approaches Etiological rather Than Descriptively Based, American Journal of Public Health, 58:8, 1968.
Haddon, W. Jr. , On The Escape of Tigers; An Ecologica1 Note, American a Journal of Public Health, 2229, 1970.
Haddon, W.Jr., Exploring the Options, Proceedings of the Conference on Research Directions Toward the reduction of Injury in the Very Young and Very Old, National Institute of Child Health and Human Development, Bethesda, MD, May 1971.
Haddon, W., Jr., Suchman, E.A., and Klein, D.,Accident Research Methods and Approaches", Harper & Row, NY 1964.
HaIl, W.K. , and O’ Day, J. , Causal Chain Approaches to the Evaluation of Highway Safety Countermeasures, Journal of Safety Research, 3:1,1971.
Harris, E.E., An Accident Is.., Hazard Prevention, 10:5,1974.
Hammer, Willie . Handbook of System and Product Safety, Englewood Cliffs, N.J. Prentice Hall, Inc., 1972.
Hartman, W. I. , Accident Investigation , National Safety Congress, Chicago, IL, 1970
Hartman, W. F., et al, The Analysis of Transportation Accident Environments –The Purpose, Method and Introductions, Sandia Laboratories, Albuquerque, NM, 1975.
Hayes, J., Private Communication about etiology of accidents.
Heinrich, H. W. , Industrial Accident Prevention, McGraw Hill, New York, NY 1936
Heinrich, H.W. Industrial Accident Prevention, New York McGraw Hill, 1969.
International Civil Aviation Organization. Manual of Aircraft Accident Investigation, Montreal: ICAO, 1971.
___Interstate Commerce Commission, Washington,, DC,.
- Motor Carrier Investigation Report No. 8, Watson Bros. Transportation Co., Inc. Accident of October 9, 1953 Near Omaha.
- Motor Carrier Accident Investigation Report No. 69, Chanps Express , Incorporated Accident of April 3, 1982 in Norwich, Connecticut. .
- Railroad Accident Investigation, Seaboard Air Line Railroad Company at Meldrin, Ga. June 28, 1959.
Jacobs, H.H. , Conceptual and Methodological Problems in Accident Research, Behavioral Approaches to Accident Research, Association for the Aid of Crippled Children , New York,. NY, 1961.
Jacobs, H. H., a Conceptual and Methodological Issues in Accident Research , Proceedings of DOT/AMA Collision Investigation Methodology Symposium, Warrenton, Va., August 1969.
Jacobs, H.H. , Towards More Effective Safety Measurement Systems, Journal of Safety Research, 2:3,197O.
Kreml, F. (Ed.) Accident Investigation Manual, Traffic Institute, Northwestern University, Evanston, IL, 1940.
Lawrence, A ,C. , Human Error as a Cause of Accidents in Gold Mining, Journal of Safety Research, 6:2 , 1974.
___The State of the Art of Traffic Safety, A.D. Little Co, Boston, MA, 1966,
___Assessment Models in Support of the Hazard Assessment Handbook, US Coast Guard Office of R & D, January 1974.
Logan, D. W, , Communicating System Safety, The PHA System Safety Newsletter , USAAVS 1:4, 1972.
McFarland, R .A,, A Critique of Accident Research, Annals of New York Academy of Science , 1O7:686, 1963,
McKe1vey, R.K. , Experiments in Injury Control : The injury Control Research Laboratory, 1966-1973, Journal of Safety Research 5:3, 1974.
Miller, C.O., Systems Approach to Accident Investigation , presentation to Flight Safety Foundation Annua1 Seminar , Montreux, Switzerland, 1969,
Nahum, A . M. , Statement during Hearings before Committee on Commerce, US Senate, Apri1 25, 1963 , Report 90–39, GPO, Washington . 1962.
National Commission on Product Safety, Final Report , GPO, Washington, DC,1970. Safety Council , Accident Facts, 1974 Edition, Chicago IL 1974.
National Safety Council . Accident Facts . Chicago IL National Safety Council, 1975.
National Safety Council, Accident Prevention Manual for industrial Operations, Chicago: National Safety Council, 1974.
National Safety Council . Supervisor's Safety Manual , Chicago:National Safety Council, 1973.
National Transportation Safety Board. Published Accident Reports. 1974, 1975, 1976, Springfield, Virginia: . National Technical Services.
New York Department of Motor Vehicles, Feasibility Study of New York State Safety Car Program, Contract C–19435, : 1966.
Oliver , J. W. , and Kaufman, R.A. , Logic Symbols Applied to Maintenance, McDonnell Douglas Corporation, Long Beach, CA , 1969.
Pask, G., Learning Behavior, in Nerve, Brain and Memory Models, Progress in Brain Research, Vol. 2, Elsevier Publishing Co., Amsterdam, 1963. .
Pask, G. , Interaction Between Individuals: Its Stability and Style. Mathematica1. Biosciences 11, 1971 ,
Peranio, A., Human Limitations and Highway Transportation –An Analysis using a Conceptual Model, CIDITVA 37, Technical Aspects of Road Safety, Fonds d'etudes et de Recherches pour la Securite Toutiere , Brussels, 1959.
Peters, George M. Product Liability and Safety, Germantown, PA Professional Seminars , l97l .
Petersen, Daniel C. Techniques of Safety Management, New York McGraw Hill, 19717
Punke, M.M., Accident Reports arid Investigation, Proceedings HRB/DOT National Conference on Rail Highway Grade Crossing Safety, Urbana, IL, 1969 ,
Recht, J. L. System Safety Analysis: A Modern Approach to Safety Problems, National Safety News (4 parts) December, 1965.
Rivas , J.R,, and Rudd , D.F., Man–Machine Synthesis of Disaster Resistant Operations, Operates Research , 23:1, 1975.
____ Role of Accident Investigation Committees, Traffic Safety, October, 1969.
Rubinsky, S, and Smith, N., Safety Training by Accident Simulation, Journal of Applied Psychology 57, 1973.,
Russam, M and Sabey, B. E., Accidents and Traffic Conflicts at Junctions , Proceedings SAE/DOT International Vehicle and Highway Safety Conference, Washington, DC, 1972.
Ryan , J. , Logic Review, National Transportation Safety Board , National Aircraft Accident Investigation School, Washington, 1970,
Shaw;, L and Sichel , H.S , , Accident Proneness, Oxford , England, 1971.
Snider, H.W. and Hall, C P, A Total Research Approach to the Study of Automobile Accidents, Temple University, Philadelphia, PA, 1968. .
Society of Air Safety Investigators, Second International Seminar, Ottawa. Camp Springs, MD SASI, 1975.
Stiska, W.C. , A Survey of Forty–three Years of Theories of Accident Susceptibility. (1919–1961) National Safety Council, Chicago, IL, 1967.
Strasser, M,K. et al, Fundamentals of Safety Education , The Macmillan Co., New York, NY, 1964 .
____ Study of the Transportation of Hazardous Materials , National Academy of Sciences , National Research Council, Washington, DC, 1969.
Suchman , E.A, , A Conceptual Analysis of the Accident Phenomenon , Behavioral Approaches to Accident Research, Association for the Aid of Crippled Children, New York, NY, 1961. .
* Surry , J., Industrial Accident Research , University of Toronto , Toronto, Canada, 1969.
Surry, J., An Annotated Bibliography for Industrial Accident Research and Related Fields , Ontario Department of Labour, Ontario , Canada,. 1969.
System Safety Society. Journal of the System Safety Society, Hazard Prevention (Monthly) . Monterey: System Safety Society.
Tarrants , W. E. , Applying Measurement Concepts to the Appraisal of a Safety Performance, Journal of the American Society of Safety . Engineers, 10:7, 1965 .
Tharp, K. J. et al , Multidisciplinary Investigations to Determine Automobile Accident Causation, Cornell Aeronautical Laboratories Buffalo, NY. 1970
* Thorndike, R.L. , The Human Factor in Accidents With Special Reference to Aircraft Accidents. USAF School of Aviation Medicine Project No. 21-30–-001, Report No 1, 1951.
Uhlenhaut, E and Enke, K, ,Vehicle Handling and Dynamics, Proceedings SAE/DOT International Vehicle and Highway Safety Conference, Washington, DC, 1972.
US Army Material Command. Fault Tree Analysis as an Aid to Improve Performance, AMC Digest, Washington, DC, May, 1971.
US Atomic Energy Commission Washington, DC, Report on Investigation of Eexplosion and Fire, Experimental Hall, Cambridge Electron Accelerator, Cambridge, MA, July 5, 1965.
- Environmental Survey of Transportation of Radioactive Materials to and. From Nuclear Power Plants, December 1972,
- Report on the Investigation of the 106T Tank Leak at the Hanford Reservation Richland, WA . July 1973.
- Report of Investigation Committee on AEC Investigation of Accidental X-ray exposure at NASL, NY on February 4, 1974.
University of Southern California. Proceedings of the Accident Prevention Symposium, Los Angeles. University of Southern California, 1974.
US Congress, Report of the Senate Committee on Commerce on S 3419, Report No. 92-749. GPO, Washington, DC, 1972.
US Department of Health, Education and Welfare, Uniform Definitions of Home Accidents, Washington, DC, 1953.
US Department of Transportation, Motor Carrier Accident Investigation Report, No. 67–12, Thunderbird Freight Lines, Inc., Accident Oct. 3, 1967 Blythe, CA.
US Department of Transportation, Bureau of Motor Carrier Safety , Summary of Accident Investigations, Washington, DC, 1972.
US Department of Transportation, Vulnerability Model , US Coast Guard Contract DOT CC 33377A, Washington, DC,1974.
US Department of Transportation, Spill Risk Analysis Program Methodology Development and Planning Phase, Final Roper t, US Coast Guard Contract DOT CG 22326A, Washington, DC, 1974.
US National Transportation Safety Board, Washington, DC,
Pipeline Accident Report, Low Pressure Natural Gas System, Burlington, IA, 1969.
*Special Study , Risk Concepts in Dangerous Goods Transportation Regulations, NTSB STS 7l-l , 1971.
*Highway Accident Report, Liquefied 0xygen Tank. Explosion followed by Fires in Brooklyn New York, NTSB HAP 71–6 l97l . .
*Marine Casualty Report , Loss of the Motor Towing Vessel Marjorie McAlester in the Atlantic Ocean, November 2, 1969. (First accident report to publish a logic tree that was subsequently validated when the vessel was salvaged several years after it sank.)
*Special Study A Systematic Approach to Pipeline Safety, NTSB PSS 72–1, 1972.
Exhibit 1–H, Docket SS–R–31 , Investigation into Collision of N&W Boxcar 49203 and GATX Tank car 41520 loaded with LPG, Puncture of tank car head and subsequent explosion, Preliminary Events Sequence Description, 1974.
Vernon , H.M. , Accidents and Their Prevention, The MacMillan Company, Cambridge, England, 1933.
Wakeland, H.H., Personal communication about numbering of events sequence chart entries for indexing purposes. 1971
Widner, J.T., (Ed) Selected Readings in Safety, Academy Press, Macon, CA, 1973.
Wigglesworth, E.C., A Teaching Mode1 of Injury Causation arid a Guide For Selecting Countermeasures, 0ccupational Psychology, 45: 2, 1972.
World Health 0rganization , Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death, Vol. 1, Geneva, 1965.
Yanowitch, R. E. et al, Aircraft as an Instrument of Self Destruction, Aerospace Medicine 44:3, 1973.
Yanowitch, R. E. et al, Psychological Reconstruction Inventory : A Postdictal Instrument in Aircraft Accident Investigation, Aerospace Medicine 43:5 1972.
References from 1972 paper Safety, Risk and Regulation to help investigators understand and deal with relationships involved in these functions during accident investigations.
Jennings, W. C. The regulator's handbook. Arlington, VA 1971.
Materials Transportation Bureau. Docket HM 110, Amendment 177-42, September 12, 1978.
National Transportation Safety Board. An overview of a bulk gasoline delivery fire and explosion (Report HZM 78-1). Washington, DC 1978.
National Transportation Safety Board, The accident performance of tank car safeguards (Report HZM 80-1). Washington, DC 1980. (a)
National Transportation Safety Board. Survival in hazardous materials transportation accidents (Report HZM 79-4). Washington, DC 1980. (b)
National Transportation Safety Board. Federal and state enforcement efforts In hazardous transportation by truck (Report SEE 81-2). Washington, DC 1981.
References for a 1972 internal risk study for NTSB titled A Risk’ÄëBased Analysis Method For Hazardous Materials Rail Transportation Safety to develop relative risks for setting program priorities.
83rd Annual Report on Transport Statistics in the United States for the Year ended December 31, 1969, Interstate Com merce Commission, Washington, D. C.
Yearbook of Railroad Facts, 1971 Edition, Association of American Railroads, Washington, D. C.
Accident Bulletin No. 1.39, Calendar Year ].970, Federal Railroad Administration, Department of Transportation, Washington, D. C.
Wage Statistics of Class 1 Railroads in the United States, Statement No. A. 300, Calendar Year 1971, Interstate Commerce Commission, Washington, D. C.
Final Phase 01 Report on Accident Review, Report RA 01 4 l6, Railroad Tank Car Safety Research and Test Project, Association of American Railroads, Washington, D. C.
National Transportation Safety Board, Washington, D. C., Railroad Accident Report, Southern Railway Company Train 154 Derailment With Fire and Explosion, Laurel, Mississippi, January 25, 1969. 11
National Transportation Safety Board, Washington, D. C., Railroad Accident Report, Chicago, Burlington, and Quincy Railroad Company Train 64 and Train 824 Derailment and Collision with Tank Car Explosion, Crete, Nebraska, February 18, 1969.
National Transportation Safety Board, Washington, D. C., Railroad Accident Report, Derailment of Toledo, Peoria and Western Railroad Company's Train No. 20 with Resultant Fire and Tank Car Ruptures, Crescent City,Illinois, June 21, 1970. 11
National Transportation Safety Board, Washington, D. C., Railroad Accident Report, Illinois Central Railroad Company Train Second 76 Derailment at Glendora, Mississippi, September 11, 1969.
deleted
National Transportation Safety Board, Washington, D. C., Special Study, Risk Concepts in Dangerous Goods Transportation Regulations."
United States Life Tables by Causes of Death, 1959 1961, U. S. Department of Health, Education and Welfare, May 1968, Washington, D. C.
Statistical Abstract of the United States, 1970, U. S. Department of Commerce, Washington, D. C.
Railroad Accident Investigation, Ex Parte No. 218, Seaboard Air Line Railroad Co., Meldrin, Georgia, June 28, 1959, Interstate Commerce Commission, Washington, D. C.
Railroad Accident Investigation Report No. 3838, Missouri Pacific Railroad, Monroe, Louisiana, Jan. 22, 1959, Interstate Commerce Commission, Washington, D. C.
BE Report No. 61, August 1968, The Bureau for the Safe Transportation of Explosives and Other Dangerous Articles, Association of American Railroads, Washington, D. C.
Communication from Southern Railway to National Transportation Safety Board, 1972.
Chauncey Starr, Social Benefit vs. Technological Risk, Science Vol. 165, September 19, 1969.
Minutes of March 25, 1971, Meeting, National Research Council, Committee on Hazardous Materials Advisory to the United States Coast Guard, Washington, D. C.
Code of Federal Regulations, Title 49, Parts 171 173, U. S. Government Printing Office, Washington, D. C.
Chauncey Starr, Benefit Cost Studies in Socio Technical Systems Proceedings of the Conference on Hazard
Evaluation and Risk Analysis, Houston, Texas, August 18 19, 1971, Division of Chemistry and Chemical
Technology, National Research Council, National Academy of Sciences, Washington, D. C.
D. Bruce Turner, Workbook of _Atmospheric Dispersion Estimates, Revised 1970, Public Health Service,
Environmental Health Service, U. S. Department of Health, Education and Welfare, Cincinnati, Ohio.
Technical Report, Washington I) C. Metropolitan Area Air Pollution Abatement Activity, Public Health Service,
U. S. Department of Health, Education and Welfare, Cincinnati, Ohio, 1967.
Federal Register, Volume 35, No. 201, Thursday, October 15, 1970, Page 16180, Docket HM 60.
Comments on Recommendations from ERA on National Transportation Safety Board's Report No. NTST3 RAR 72 2, dated August 19, 1972.
Hazardous Materials Regulations Board Public Docket Files (Docket No. HM 60), Department of Transportation, 400 6th Street, S. W., Washington, D. C. 20590.
op. cit. 49 CFR, Part 213
B. J. Garrick, W. C. Gekler, 0. C. Baldonado, H. K. Elder, and J. E. Shapely, A Risk Model for the Transport of Hazardous Materials, prepared for Department of the Army, Fort Detrick, Maryland 21701, under Contract No DAAA13068 C
These references are contained in a 1975 paper Accident Theory And Accident Investigation about the theoretical basis for investigation practices.
Benner, L., 1975: Accident Investigation: Multilinear Events Sequencing Methods, Journal of Safety Research, 7:2, June 1975.
Webster's Third New International Dictionary, 1971, G & C Merriam Company, Springfield MA.
Greenwood, M. and H.M. Woods, 1919: A Report on the Incidence of Industrial Accidents Upon Individuals With Special Reference to Multiple Accidents. British Industrial Fatigue Research Board, No. 4.
Newbold, E.M., 1926: A Contribution to the Study of the Human Factor in Causation of Accidents. British Industrial Health Research Board, No. 34.
Ames, J.S., 1928: First National Aeronautical Safety Conference, 17th Annual Safety Congress, National Safety Council Transactions, Chicago, IL.
Heinrich, H.W., 1936: Industrial Accident Prevention, McGraw Hill, New York, NY.
Kreml, F. (ed.), 1940: Accident Investigation Manual, Traffic Institute, Northwestern University, Evanston, IL.
Baker, J.S., 1963: Traffic Accident Investigator's Manual for Police, Northwestern University, Evanston, IL.
Driessen, G.J., 1970: Cause Tree Analysis, Measuring How Accidents Happen and the Probabilities of Their Cause. Presented to American Psychological Association, September, 1970, Miami,FL.
U.S. Army Materiel Command, 1971: Fault Tree Analysis as an Aid to Improved Performance, AMC Safety Digest, May 1971, Washington, D.C.
Civil Aeronautics Board, 1962: Aircraft Accident Report SA 361, United Airlines, Inc. DC-8 N 8013 U, and Transworld Airlines, Inc.Constellation 1049A N 6907 C, Near Staten Island, NY, December 16, 1960.
Haddon, W., Jr., 1968: The Changing Approach to Epidemiology, Prevention and Amelioration of Trauma; the Transition to Approaches Etiological Rather than Descriptively Based, American Journal of Public Health, 58:8.
Surry, J., 1969: Industrial Accident Research, University of Toronto, Toronto, Canada.
Perchonok, 5., 1969: Multidisciplinary Investigation to Determine Automobile Accident Causation, Report No. 5, Cornell Aeronautical Laboratory, Inc., October, 1969.
Benner, L., 1975: D.E.C.I.D.E. in Hazardous Materials Emergencies, Fire Journal, 69:4, July, 1975.
U.S. National Transportation Safety Board, 1971: Highway Accident Report HAR 71-6, Liquefied Oxygen Tank Explosion Followed by Fires in Brooklyn New York, May 30, 1970.
Benner, L., 1975: D.E.C.I.D.E. in Hazardous Materials Emergencies, Fire Journal, 69:4, July, 1975.
U.S. National Transportation Safety Board, 1973: Aircraft Accident Report AAR 73--16, United Air Lines, Inc. Boeing 737, N9031U Chicago--Midway Airport, Chicago, IL.
U.S. National Transportation Safety Board, 1971: Marine Casualty Report Loss of the Motor Towing Vessel Marjorie McAllister in the Atlantic Ocean, November 2, 1969.
Benner, L., 1975: Risk, Responsibility and Research, presentation to the Council Committee on Chemical Safety of the American Chemical Society, Chicago, IL, August 20, 1975
These references were in a 1975 paper introducing Multilinear Events Sequencing for Accident Investigations. based on a process model for accident phenomena, and using data matrix arrays for displaying input data about those processes, and integrating the input data during investigations.
Ames, J. S. Aircraft accidents-method of analysis. Transactions of the National Safety Council, 17th Annual Congress. Chicago: National Safety Council, 1928.
Baker, J. S. Problems of deteRmining causes of specific accidents. Evanston, Ill.: Traffic Institute, Northwestern University, 1953.
Baker, J. S.; & Ross, H. L. Concepts and classification of traffic accident causes. Evanston, Ill.: Traffic Institute, Northwestern University, 1960.
Benner, L. Safety, risk and regulation. Transportation Research Forum Proceedings, Chicago, 1972,13, 1.
Driessen, C. G. J. Cause tree analysis: Measuring how accidents happen and the probabilities of their cause. Paper presented at the 78th Annual Convention of the American Psychological Association, Miami, September, 1970.
Haddon, W. Jr., On the escape of tigers: An ecological note. American Journal of Public Health, 1970, 2229.
Heinrich, H. W. Industrial accident prevention. New York: McGraw Hill, 1936.
Johnson, W. C. MORT: The management oversight and risk tree. Journal of Safety Research, 1975, 7, 4-15.
Lawrence, A. C. Human error as a cause of accidents in gold mining. Journal of Safety Research, 1974, 6, 78-88.
Pask, G. Learning behavior, in nerve, brain and memory models. In Progress In Brain Research (Vol.2). Amsterdam: Elsevier Publishing Co., 1963.
Surry, J. Industrial accident research. Toronto, Canada: University of Toronto, 1969.
US National Transportation Safety Board. Special study, risk concepts in dangerous goods transportation regulations. NTSB STS 71-1, Washington, D.C., 1971.
Wakeland, H. H. Personal communication, 1971.
References from a 1976 paper Hypothesis Generation for Rare Events Research offering observations about hypothesis generation during accident investigations, which led toBackSTEP" element of MES investigation technology, and subsequent identification of the proper time to develop hypotheses during investigations.
Benner, L ., Accident Investigations: Multilinear Events Sequencing Methods. Journal of Safety Research, 1975, 7(2), 67-73
Polya, G. How to Solve It, Doubleday-Anchor Books, Second Edition, Garden City, New Jersey; 1957.
Popper, Karl The Logic of Scientific Discovery, Basic Books, Inc., New York, New York, 1959.
Surry, J. Industrial Accident Research, University of Toronto, 1969.
,p>References from 1977 paper A Progress Report on Risk Analysis discusses the changing climate in which publicsafety" decisions are being made.
References from a 1978 paper Accident Theories and their Implications for Research raising the issue of a theoretical basis for accident investigation processes, and their significance for safety research.
Accident Prevention Manual for Industrial Operations., National Safety Council, Chicago, IL 1976.
Accident Investigations and Reporting, Instruction 5102.1, Chief or Naval Operations, Department of Defense, 18 May 1977.
Heinrich, H.W., Industrial Accident Prevention., New York, McGraw Hill 1936.
Haddon, W. Jr., The Changing Approach to the Epidemiology, prevention and Amelioration of Trauma: The Transition to Approaches Etiologically Rather than Descriptively Based., American Journal of Public Health 58:8, 1968
Us Standard Method of Recording Basic Facts Relating to the Nature and Occurrence of Accidents,, Z et seq. American National Standards Institute, New York 1962.
Greenwood, M. and Woods, HM, A report on the incidence of industrial accidents upon individuals with special reference to multiple accidents., British Industrial Fatigue Research Board No. 4, as discussed in reference 8.
Newbold, E.M., A contribution to the study of Human Factors in Causation of Accidents., British Industrial Health Research Board, No. 34, as discussed in reference 8.
Thorndike, R.L., The Human Factor in Accidents,, A project report for the US Air Force with special reference to Aircraft Accidents, reprinted by US Department of Health, Education and Welfare, Public Health Service, Washington, DC 1951.
Fault Tree Analysis as an Aid to Improved Performance., AMC Safety Digest, US Army Materiel Command, May 1971.
Fault Tree For Safety., D-6-75133, The Boeing Company, Seattle, WA 1966
Benner, L., Accident Theory and Accident Investigation., Proceedings of the Society of Air Safety Investigators Annual Seminar, Ottawa Canada, October 1975.
Haddon, W. Jr., Reducing the damage of Motor Vehicle Use., Technology Review 77:8 1975.
Joksch, H.C., Reidy, J.C.Jr., and Ball, J.T., Construction of a Comprehensive Causal Network, Phase III, Final Report (Volume 1), Center for the Environment and Man, Inc., Windsor, CT 1977.
Haight, F., et al, ;Review of Methods for Studying Pre—Crash Factors., Department of Transportation DOT HS 802 056, Washington DC 1976.
References from a 1980 paper Accident investigation: A Case for New Perceptions and Methodologies reported the differing perceptions of accident phenomena and methodologies used for accident investigtions, explained their consequences for investigations and safety, and argued for new thinking.
American National Standards Institute, US Standard Method of Recording Basic Facts Relating to the Nature and Occurrence of Work Injuries, ANSI 216.2’Äî1962 (Rev. 1969) New York 1962
Feasibility of.securing research-defining accident statisticsSafety Sciences, Dept. of Health Education and Welfare, National Institute of Safety and Health Publication No. 78180, Sept. 1978
Haddon, W. Jr., Reducing the Damage of Motor Vehicle Use.Technology Review 77:8, Aug. 1975
McGrew, D.R., Traffic Accident Investigation and Physical Evidence.Thomas, Springfield, IL 1975
Hall, W.K. and O’ÄôDay, J., Causal Chain Approaches to the Evaluation of Highway Safety Countermeasures.J. Saf. Res. 3:1 1971
US National Transportation Safety Board, Letter to Secretary of Transportation transmitting Safety Recommendations 1769 through 17611, October 20, 1976
Pask, G., Interaction between Individuals: Its Stability and Style. Mathematical Biosciences 11, 1971
McGlade, F.S., Adjustive Behavior and Safe Performance. in Ferry, T.S. and Weaver, D.A., Directions in Safety’Äù, Thomas, Springfield, IL 1976
Blumenthal, M., Problem Definition: The Driving Task in the System Context. Behavioral Research in Highway Safety, 2:1, Spring 1971
Benner, L., Hazardous Materials Emergencies Lufred Industries, Inc., Oakton, VA 1976
US National Transportation Safety Board, Derailment of Missouri Pacific Railroad Company Train 94 at Houston, Texas, October 19, 1971 NTSB RAR’Äî72’Äî6, 1972
Benner, L., Four Accident Investigation Games Simulations of the Accident Investigation Process. Lufred Industries, Inc. Oakton, VA 1979 .
Ames, J.S., Aircraft Accidents: Method of Analysis. Proceedings of National Safety Council, 17th Safety Congress, 1928
Heinrich, H.W., Industrial Accident Prevention McGraw Hill, New York 1936
Thorndyke, R.L., The Human Factor in Accidents US Air Force School of Aviation Medicine, Project Report, Project No. 21’Äî30’Äî001, 1951
US Dept. of Health, Education and Welfare, Public Health Service, Uniform Definitions of Home Accidents. Washington, DC 1958
Fault Tree Analysis as an aid to Improved Performance AMC Safety Digest, US Army Materiel Command, May 1971
Fault Tree for Safety D57133, The Boeing Company, Seattle, WA 1966
Suchman, E.A., A Conceptual Analysis of the Accident Phenomenon in Behavioral Approaches to Accident Research, Association for the Aid of Crippled Children, New York 1961
Baker, J.S., Traffic Accident Investigator's Manual for Police Northwestern University, Evanston, IL 1963 (Revised 1971)
Haddon, W. Jr., The changing Approach to the Epidemiology, Prevention and Amelioration of Trauma: The Transition to Approaches Etiologically rather than Descriptively Based. American Journal of Public Health 58:8, Aug. 1968
Surry, J. Industrial Accident Research University of Toronto, Toronto, Ontario, Canada, 1969
Johnson, W.G., The Management Oversight and Risk Tree prepared for the US Atomic Energy Commission under Contract AT (043)821, Feb.1973
Benner, L. Safety Risk and Regulation Proceedings, Transportation Research Forum, Vol. XIII, No. 1, Chicago, IL 1972
Wigglesworth, E.C., A Teaching Model of Injury Causation and a Guide for Selecting Countermeasures Occupational Psychology 48:2, 1972
Leplat, J., Origin of Accidents and Risk Factors paper presented on a Seminar sponsored by the Swedish Work Environment Fund, Stockholm, 1975
Joksch, H.C. Reidy, J.C. Jr., and Ball, J.T., Construction of a Comprehensive Causal Network, Phase III, Final Report, Vol. I Center for the Environment and Man, Inc. Windsor, CT 1977
Benner, L., Risk Responsibility and Research paper presented to the Symposium sponsored by the American Chemical Society Council Committee on Chemical Safety, Chicago, IL, August 26, 1975.
Wright, C., Railroad and Emergency Response Personnel: A Cooperative Effort presented to Hazardous Materials Workshop, 106th Annual Conference, International Association of Fire Chiefs, Kansas City, Mo. September 17, 1979
US National Transportation Safety Board, Improving Survivability in Hazardous Material Accidents Report HZM 795
Dieterly, D.L., Accident Analysis: Application of the Decision/Problem State Analysis Methodology AFHRL Technology Office, NASAAMES Research Center, Moffett Field, Ca. 1978 (In publication)
Manual of Aircraft Accident Investigation, Fourth Edition, International Civil Aviation Organization Document 6920AN/855/4, Montreal, Canada 1970
from a 1981 paper Methodological Biases Which Undermine Accident Investigations with a status report of ongoing research into accident investigation theory, principles and practices, in support of advanced accident investigation courses conducted for the University of Southern California, to overcome biases in opinions about accident causation among investigators.
Editor's Cornered, ISASI forum, Vol. 14:2, Summer 1981.
"Disagreement about Tenerife Crash," Foresight, August 1981
Petitions from Air Line Pilots Association to the National Transportation Safety Board, June 9,1980 and June 15, 1981.
The President's Task Force on Aircraft Crew Complement, Report of the Mishap Analysis Panel Working Group Concerning the Boeing Study, "Jet Transport Safety Record, May 5, 1981.
Report of the President's Commission on THE ACCIDENT AT THREE MILE ISLAND, The Need For Change: The Legacy of TMI, October, 1979.
"Three Mile Island, A Report to the Commissioners and to the Public" by the Special Inquiry Group of the Nuclear Regulatory Commission, Mitchell Rogovin, Di-rector, May 1980.
U.S. Nuclear Regulatory Commission, "Investigation into the March 28, 1979 Three Mile Island Accident by the Office of Inspection and Enforcement" (NUREGA)600 Draft), October 10, 1979.
Electric Power Research Institute, "Analysis of Three Mile Island-Unit 2 Accident," NSAC- 1, July 1979.
See list of relevant references in Miller, C.O., "Safety Management Factors Germane to the Nuclear Reactor Accident at Three Mile Island, March 28, 1979", Hazard Prevention, Vol.16, Special Issue, Summer, 1980.
Ferry, T.S., "Modern Accident Investigation and Analysis: An Executive Guide," John Wiley and Sons, New York, 1981
Benner, L., "Accident Theory and Accident Investigation," Proceedings of the ISASI Annual Seminar, Ottawa, Canada, 7-9 October, 1975.
Benner, L., "Accident Perceptions: A Case for New Perceptions and Methodologies", SAE Transactions, Vol. 89, 1980.
Ferry, op cit, p.166-172.
NTSB "Survival in Hazardous Materials Accidents", Report HZM-80-4, 1980.
NTSB "Phosphorus trichloride Release in Boston and Maine Yard 8 During Switching Operations, Somerville, Massachusetts, April 3,1980", Report HZM-81-1.
references are from a 1981 white paper presented at a system safety symposium White Paper No. 1 System Safety Methodology that provided an overview and discussions of what a methodology is, and the concepts, principles and techniques involved in the application of the system safety methodology.
American Institute of Chemical Engineers, LOSS PREVENTION, through Volume 14, AIChE, New York
Brown, D.B., SYSTEMS ANALYSIS AND DESIGN FOR SAFETY Prentice Hall Englewood Cliffs, NJ, 1976
Grimaldi, J. and Simonds, R.H., SAFETY MANAGEMENT, Richard D. Irwin, 1975
4. Hammer, W., PRODUCT SAFETY MANAGEMENT AND ENGINEERING, Prentice Hall, Englewood Cliffs, NJ, 1980
Johnson, W. THE MANAGEMENT OVERSIGHT AND RISK TREE/MORT, U.S. Atomic Energy Commission SAN 82l2, l973
System Safety Society, INTERNATIONAL SYSTEM SAFETY CONFERENCE PROCEEDINGS, (1973, 1975, 1977, 1979; refer to appended indexes)
U.S. Air Force Systems Command, DESIGN HANDBOOK DHl6, SYSTEM SAFETY, 3 April 1979
U.S. Department of Defense, MILITARY STANDARD, SYSTEM SAFETY REQUIREMENTS, MILSTD882A, Washington, D.C., 1977
U.S. Department of the #000080, NAVORD OD 44942, WEAPON SYSTEM SAFETY GUIDELINES HANDBOOK, PARTS 1IV, 15 January 1974
U.S. National Transportation Safety Board, RISK CONCEPTS IN DANGEROUS GOODS TRANSPORTATION, Report No, NTSB STS7 11. NTIS, 1971
U.S. Nuclear Regulatory Commission, FAULT TREE HANDBOOK, NUREGO492, GPO, Washington, D.C., 1981
References from 1983 paper What is this thing called a Safety Regulation? proposes that investigators consider the nature of a safety regulation as a pre-made and preemptive task decision prescribed by some authoritative entity, and implications of that view.
Jennings, W. C.The regulator's handbook. Arlington, VA: Author, 1971.
Materials Transportation Bureau. Docket HM 110, Amendment 177-42, September 12, 1978.
National Transportation Safety Board. An overview of a bulk gasoline delivery fire and explosion (Report HZM 78-1). Washington, DC: Author, 1978.
National Transportation Safety Board, The accident performance of tank car safeguards (Report HZM 80-1). Washington, DC: Author, 1980. (a)
National Transportation Safety Board. Survival in hazardous materials transportation accidents (Report HZM 79-4). Washington, DC: Author, 1980. (b)
National Transportation Safety Board. Federal and state enforcement efforts In hazardous transportation by truck" (Report SEE 81-2). Washington, DC: Author, 1981.
References from 1983 paper System Safety's Open Loop arguing that system safety and risk analyses lack a long-term feedback loop established to convey the ’Äúsystem safety score’Äù achieved by the analyst.
U.S. Department of Defense, “Military Standard System Safety Program Requirements,” MIL-STD-882A, June 28, 1977
Brown, D.B., Systems Analysis and Design for Safety, Prentice Hall, Englewood Cliffs, N.J. 1976
Hammer, W., Product Safety Management and Engineering, Prentice Hall, Englewood Cliffs, N.J. 1980.
Vesley, W.E. et al, Fault Tree Handbook, NUREG 0492, U.S. Nuclear Regulatory Commission, Washington, D.C. 1981.
Malasky, S., System Safety: Technology and Application, Garland STPM Press, New York 1982.
Clemens, P.L., A Compendium of Hazard Identification & Evaluation Techniques for System Safety Application, Sverdrup Technology, Inc., AEDC Group, Arnold Air Force Station, TN 1981.
Roland, H.E. and Moriarty, B., System Safety Engineering and Management. John Wiley, New York, 1983
These references are from a 1985 study Rating Accident Models and Investigation Methodologies which developed and applied rating criteria to rate and rank investigation practices in US governmental organizations.
Benner, L(1977)Accident theory and accident investigators Hazard Prevention, 13, 18’Äî21.
Benner, L(1978)Four accident investigation games Oakton, VA: Lufred Industries, Inc.
Benner, L(1979)Crash theories and their implications for accident research American Association for Automotive Medicine Quarterly Journal, 1, 24’Äî27.
Benner, L(1981a)Accident investigation ’ÄîA case for new perceptions and methodologies (Publication No. 800387)Warrendale, PA: Society of Automotive Engineers.
Benner, L(1981b)Accident perceptions: Their implications for investigators International Society of Air Safety Investigators Forum, 14, 13’Äî17.
Benner, L(1981c)Methodological biases which undermine accident investigations Proceedings of International Society of Air Safety Investigators International Symposium, 1’Äî5.
Benner, L(1983a)Task report no1: Accident models and investigation methodologies employed by U.S. government agencies in accident investigation programs (Contract No41USC252G3)Washington, DC: OSHA.
Benner, L(1983b)Task report no2: Potential impacts of preferred accident model and investigation methodology on OSHA accident investigations
Benner, L(1983c)Task report No3: Summary report of
projected benefits and risk associated with OSHA’ÄôS adoption of preferred accident models and investigation methodology (Contract No41USC252C3)Washington, DC: OSHA.
Benner, L(1983d)Task report No4: Upgrading OSHA accident investigations with best available accident model and investigation methodology: Recommended implementation steps (Contract No41U5C252C3). Washington, DC: OSHA.
Benner, L(1984)Safety’Äôs future shock I Paper presented at the Department of Energy Environmental, Safety and Health Seminar Series for 1984, Germantown, MD.
Benner, L., & White, L(1984)Accident investigators handbook for category I and II investigations (Final Report to Minerals Management Service, Contract No14-12-0001-30038)Oakton, VA: Events Analysis, Inc.
Haddon, W., Suchman, EA., & Klein, D(1964)Accident research New York: Harper and Row.
Hasselberg, R(1983)Personal communication U.S. Nuclear Regulatory Commission, Chattanooga, TN.
Henderick, K(1983)Personal communicationU.S. Coast Guard.
Johnson, W(1973)The management oversight and risk tree-MORT (SAN 821-2)Germantown, MD: U.S.Atomic Energy Commission.
Johnson, W(1980)MORT safety assurance system New York: Marcel Dekker.
King, K(1977)Feasibility of securing research-defining accident statistics(Publication 78-180) Cincinnati, OH: NIOSH.
Kjellen, U(1982)The deviation concept in occupational accident research ’Äî Theory and method (draft version)Stockholm, Sweden: Occupational Accident Research Unit, Royal Institute of Technology.
Mayo, LW(Ed.) (1961)Behavioral approaches to accident research New York: Association for the Aid of Crippled Children.
McDevitt, J., & Benner, L(1981)White paper no1: System safety methodology for conference on the state of the art of system safety Hazard Prevention, 18, 26’Äî31.
Moriarty, B(1981, April)Statement of the system safety society before the U.S Department of Labor, Occupational Safety and Health Administration on regulation of hazardous materials Subpart H, 2 CFR 1910.
National Aeronautics and Space Administration(1981)L39A mishap investigation board report Cape Kennedy, FL
National Materials Advisory Board, National Research Council(1980)The investigation of grain elevator explosions (NMAB-367-1)Washington, DC
National Transportation Safety Board(1978)An overview of a bulk gasoline delivery fire and explosion (Report HZM 78-1)Washington, DC
Safety Sciences(1980)Briefing on procedures manual for use of the NIOSH accident investigation methodology ’ÄúAIM’Äù (Contract No210-78-0126)Morgan-town, WV
Surry, J(1969)industrial accident research, a human engineering appraisal Toronto: University of Toronto Dept of Industrial Engineering. U.S. Congress(1970, December)Public Law 91-596U.S. Department of Labor(1982)OSHA Instruction CPL 2.45, Field operations manual with revisions through 1982. Washington, DC
U.S. Department of Transportation(1982)DOT form 5800 report data base.) Washington, DC: Materials Transportation Bureau.
U.S. Energy Research and Development Administration (now U.S. Deptof Energy)Accident incident investigation manual (ERDA 76-20)Washington, DC: U.S. Government Printing Office. APPENDIX: AGENCY DOCUMENTS REVIEWED __
Baker, J5(1975)Traffic accident investigation manual Evanston, IL: The Traffic Institute, Northwestern University(Cited by U.SDOT/FHWA as basis for investigations)
Consumer Product Safety Commission(1980, October)In-depth accident investigations (Order 9010.24). Washington, DC
International Civil Aviation Organization(1979, March)Aircraft accident investigation (Annex 13)(The United States is a signatory to the ICAO treaty)Montreal, Canada
Library of Congress Library of congress regulations LCR1817-1 and LCRL8L7-4Washington, DC
National Aeronautics and Space Administration(undated)Basic safety requirements (VolI) (NASA SHB 1700.1)Washington, DC
National Institute for Occupational Safety and Health(1978)Feasibility of securing researching-defining statistics (Technical Report No78-180)Cincinnati, OH
National Institute for Occupational Safety and Health(1980)Procedures manual for use of the NIOSH accident investigation methodology (AIM)Morgantown, WV
National Materials Advisory Board, National Academy of Sciences, Panel on Causes and Prevention of Grain Elevator Explosions (1981a) Investigation of grain elevator explosions (NMAB 367-1) Washington, DC
National Materials Advisory Board, National Academy of Sciences, Panel on Causes and Prevention of Grain Elevator Explosions(1981b)Prevention of grain elevator and mill explosions (NMAB 367-2)Washington, DC
National Materials Advisory Board, National Academy of Sciences, Panel on Causes and Prevention of Grain Elevator Explosions (1981c)Pneumatic dust control in grain elevators (NMAB 367-3)Washington, DC
National Transportation Safety Board(1975)Inquiry manual, aircraft accidents and incidents (Order 6200.1). Washington, DC
Navy Department(1978)Aircraft safety engineering accident investigation guide (NAVAIR 00-80T-67-1). Washington, DC
Navy Department(1981)Handbook for the conduct of forces afloat safety investigations (NAVSAFCEN 5102/29)Washington, DC
Navy Department(1982, April)Mishap investigation and reporting OPNAVINST 5102lA)Washington, DC U.S. Coast Guard(1982)Mishap investigating and reporting (COMDTINST 5100.29)Washington, DC
U.S.Code of Federal Regulations, Titles 10, 14, 16, 29, 30, 32, 33, 41, 42, 49 in 1982 issues of CFT Washington, DC: U.S.Government Printing Office.
U.S.Code of Federal Regulations, Title 49, chapter 800’Äî 831, Regulations of the National Transportation Safety Board, 1982Washington, DC: U.S.Government Printing Office.
U.S. Department of the Air Force(1972, March)Investigation of USAF aircraft accidents (AFR 127-1). Washington, DC
U.S. Department of the Air Force(1979, May)The U.S.Air Force mishap prevention program (AFR 127-2). Washington, DC
U.S. Department of the Air Force(1980, January)Investigating and reporting USAF mishaps (AFR 127-4). Washington, DC
U.S. Department of the Army(undated)Procedures for investigating officers and boards of officers (Army Regulation 15-6)Washington, DC
U.S. Department of the Army(1980, September)Accident reporting and records (Army Regulation 385-40). Washington, DC
U.S. Department of Defense(1977, June)Military standard 882a, System safety program requirements. Washington, DC
U.S. Department of Energy(1976a)Accident/incident investigation manual (ERDA 76.20)Germantown, MD
U.S. Department of Energy(1976b)MORT Users manual (ERDA-76-45/4 1976, Rev1)Germantown, MD
U.S. Department of Energy (1978) Events and causal factors charting (DOE 76-45/14, Rev1) Germantown, MD
U.S.Department of Energy (1982a) Environmental protection, safety and health protection information reporting requirements (Order DOE 5484.1) Germantown, MD
U.S. Department of Energy (1982b) Environmental protection, safety and health protection program for DOE Operations (Order DOE 5480.1) Germantown, MD
U.S. Department of Labor (1977) OSHA 2288 investigating accidents in the workplace (A manual for compliance, safety and health officers) Washington, DC
U.S. Department of Labor (1982) OSHA instruction CPL 2.45 Field Operations Manual (Chapter XVI and Chapter V) Washington, DC
U.S. Department of Labor, Mine Safety and Health Administration, National Mine Health and Safety Academy. (undated)Special investigations field operations manual Arlington, VA
U.S. Department of Labor, National Mine Health and Safety Academy(1978)Safety manuals Nos1’Äî10. Beckley, WV
Benner, L., 5 Accident Perceptions Professional Safety, February 1982. p 21
Roblee, C. L. and McKechnie, A. J., The Investigation Of Fires(1981) Prentice Hall, Englewood Cliffs, NJ
C. Perroni in Fire Journal, July-August 1989, p 27.
Prosser, W.L., Wade, J. W. and Schwartz, V. F., Cases And Materials On Torts , (1976) The Foundation Press, Inc., Mineola, NY, p 345
Hendrick, K.M. and Benner, L., Investigating Accidents With Step (1986). Marcel Dekker, New York. p 17-22.
National Fire Academy, Fire Arson Detection, Student Manual, Unit 2 (1983) Federal Emergency Management Agency, Emmetsburg, MD p 1
Carroll, J. J., Fire And Arson Investigation, (1979), Charles C. Thomas, Springfield, IL p 83.
NITS FIRS system.
NFPA 906M
NFPA 906M-10
Report of the Dupont Plaza or MGM fires
Michigan v Tyler et al, Supreme Court of the United States, May 31, 1978, No. 76-1608 for an insightful discussion relevant to this objective.
Perroni, C., _________ Fire Journal, July/August 1989, p 25
NITS FIRS reports, for example.
Drysdale, D., An Introduction To Fire Dynamics (1985), John Wiley & Sons, NY p 1
U. S. Dept. of Energy Mort Accident Investigation Manual , SSDc 27, Second Edition, (1985), System Safety Development Center, Idaho Falls, ID
Harvey, M. D., Models For Accident Investigation, (1985) Alberta Workers' Health, Safety and Compensation, Edmonton, Alberta
Reference from a 1990 paper Safety Training's Achilles Heel discussing the effects of flawed investigations
on safety training activities.Benner, L., D.E.C.I.D.E. In Hazardous Materials Emergencies Fire Journal, Boston, MA, p. 21-26
Driver, E. T. and Benner, L., (1980) Evaluating Dangerous Goods Emergency Response with Time/Loss Analyses, Proceedings of 6th International Symposium-Packaging and Transportation of Radioactive Materials, November 1-14, 1980, Berlin (West), Federal Republic of Germany
Ericksen, N., Kefer, W., and Wright, C., (1989) Introduction to Hazardous Materials Incident Response, Union Pacific Railroad Company and Environmental Protection Agency, Region VII, Omaha, NE
Federal Emergency Management Agency, (1985) Hazardous Material Incident Analyses, National Emergency Training Center, Emmitsburg, MD p vii
Federal Emergency Management Agency, (1985) Recognition and Identification of Hazardous Materials, National Emergency Training Center, Emmitsburg, MD p vi
Grimes, Martin, (1974) Hazardous Materials Transportation Accidents, Fire and Explosion Potential Serious Threats to Fire Fighters, Topical Information Bulletin 1- 74, Fire Command, Boston, MA p 15-18
Haessler, W.M., (1974) The Four Problems of Transportation of Goods, Fire Journal, Boston, MA p6-11.
Hendrick, K. and Benner, L., (1987) Investigating Accidents with Step, Marcel Dekker, New York, NY
Hendrick, K., (1990) Systematic Safety Training, Marcel Dekker, New York, NY
National Fire Protection Association, (1978) Hazardous Materials Transportation Accidents, SPP-49, Boston, MA Articles republished include:
National Transportation Safety Board, (1972) Railroad Accident Report: Derailment of Missouri Pacific Company’s Train 94 at Houston, Texas, October 19, 1971, Report RAR-72-6, National Technical Information Service, Springfield, VA
National Transportation Safety Board, (1981) Phosphorus Trichloride Release in Boston and Main Yard 8 During Switching Operations. Somerville, MA, April 3, 1980, Report HZ 81-1, National Technical Information Service, Springfield, VA (chart)
National Transportation Safety Board, (1971) Risk Concepts in Dangerous Goods Transportation, SS-71-1, National Technical Information Service, Springfield, VA
Noll, G., Hildebrand, M. and Yvorra, J., (1988) Hazardous Materials: Managing the Incident, Fire Protection Publications, Oklahoma State University, Stillwater, OK
References from a 1992 paper Ranking Safety Recommendation Effectiveness which argues that safety investigation recommendation practices are inadequately conceived, organized, staffed or monitored, resulting in major deficiencies in the recommendation development process.
ICAO Annex 13 Accident Investigation Manual, p I-1-1 (1970) " establishing probable cause thereof, so that appropriate steps may be taken to prevent recurrence of the accident and the factors which led to it." The utilization of "cause" or "cause factor" data and "causation models" is widely used in present safety research projects to develop recommended safety actions from aggregated accident data.
ICAO Accident Prevention Manual 1984, 4.2.25, "Accident investigation includes an analysis of the evidence to determine all causes - a process leading to the formulation of safety recommendations." The Department of Energy's Accident Investigation Manual, DOE/SSDC 76-45/27 , p 122 contains similar guidance: " judgments of needs specify what needs to be done now in response to the accident investigation findings and probably causes."
Accident Prevention Manual 1984, p 31, "Recommendations must cover all hazards revealed during the investigation - not just those directly concerned with the causes."
NTSB /RAR -91-04, PB 916304, p 47-49
NTSB Order NTSB 82, June 11, 1987,
My experience suggests that this ratio should be more nearly in the range of a 50/50 to 60/40 split, but no hard data about this distribution are available.
Tables 1-3 and p 6 in Benner, L., APPLYING SYSTEM SAFETY TO THE SAFETY RECOMMENDATION PROCESS, in the Proceedings of the 10th International System Safety Conference, Dallas, TX 1991, 4.4-5-1
ICAO Accident Prevention Manual 1984, 4.5.1 " . . . Valid comparisons can be based on rate [of accidents, incidents, fatalities, etc.] information."
For an instructive case study of this phenomenon, consult the legislative history of PL 93-633 establishing the independent National Transportation Safety Board in 1973 after the Turkish Air accident in Paris.
Wood (HOW DOES THE INVESTIGATOR DEVELOP RECOMMENDATIONS?, 1979) has written on how investigators develop recommendations for the International Society of Air Safety Investigators, (ISASI) whose members' explicit goal is accident prevention through investigation, but does not offer a process description. Bruggink and Fritsch (THE SAFETY RECOMMENDATION PROCESS, 1989) make the point to ISASI members that the safety recommendation process is far from standardized, and for that reason is not as effective as it should be, but do not describe the processes or specific deficiencies.
For a fuller discussion of this difference, see Hendrick, K.M. and Benner, L. INVESTIGATING ACCIDENTS WITH STEP, 1987, Marcel Dekker, NY p 197.
Ferry, T., MODERN ACCIDENT INVESTIGATION AND ANALYSIS, 2nd Edition, Wiley Interscience, New York, NY 1988, p 236. "If recommendations are so important, why don't we develop expert recommenders?"
ICAO Accident Prevention Manual, First Edition, 1984, 4.2.25.
"Thinkload" is the work effort devoted to the mental processes that drive actions taken, and include the conceptual and knowledge inputs, the mental processes employed to gather, organize, integrate, and otherwise mentally work with the inputs to arrive at outputs such as the decisions, viewpoints, concerns, comments, conclusions, judgments and mental outputs flowing from the mental processes. The term is used to differentiate between the performance of purely thinking tasks, as contrasted with all other kinds of tasks .
SSDC 27, 1976 MORT Accident Investigation Manual or Johnson, W., MORT SAFETY ASSURANCE SYSTEMS, 1980, Marcel Dekker, New York, NY
Department of Transportation Docket HM 144, covering tank car head shield regulations, for a major exception to this observation. A 95% effectiveness of the recommended action was predicted; my last knowledge of the follow-up record showed an actual reduction in the target scenarios of over 96% during a 4 year follow-up period.
See list of governmental agency investigation manuals reviewed in Benner, L., RATING ACCIDENT MODELS AND INVESTIGATION METHODOLOGIES, Journal of Safety Research, Vol. 16, 1985, p 125-6.
Appendix B from NTSB Order 82, published in 1987. adapted from work encouraged by H. H. Wakeland, former Director of the Bureau of Surface Transportation Safety at the NTSB in the mid-1970s.
Hendrick & Benner, op cit, Chapter 8-10 on recommendation development tasks and procedures, as well as evaluation criteria and quality control ideas.
See full discussion of this issue of misdirected follow-up efforts, in Reference 7, p 11,
ICAO ACCIDENT PREVENTION MANUAL, section 4.5 Measurement of Safety, which asserts that only loss counts and rates can be used, a totally retrospective approach that ignores system safety approaches.
Benner, L. and Rimson, I. , ACCIDENT INVESTIGATION QUALITY CONTROL, ISASI forum 25:1 for a discussion of the ideas and methods.
Benner, L. "FIRE RISKS IN CARLOAD/TRUCKLOAD TRANSPORTATION OF CLASS A EXPLOSIVES", Report to Department of Transportation, OHMT, Contract No. DTRS57-88-P-82656, March, 1989
White, L and Benner, L., "Corrective Action Evaluation" Proceedings of 1985 System Safety Conference, 3.4.5.1, System Safety Society
SSDC, op cit, p 444--448 for one of the most condensed, most useful and most practical discussions of the need for and use of priorities in establishing safety program action agendas. Without indicators of the significance of safety problems such a priority problem list is impossible to compile or use for guidance.
The Institute for Nuclear Power Operations uses a facility evaluation process that might serve as a model for this kind of exchange process.
References cited in a 1993 paper Mishap Investigations: Tools for Evaluating the Quality of System Safety Program Performance that argues that mishap investigations are opportunities to validate the quality of analysts’Äô predictive documents, and are not but should be so used.
Fischhoff, Baruch and J. F. Merz. "The Inconvenient Public: Behavioral Research Approaches to Reducing Product Liability Risks". Product Liability and Innovation . Washington: National Academy Press, 1994.
_____Guidelines for Investigating Chemical Process Accidents. New York: Center for Chemical Process Safety of the American Institute of Chemical Engineers, 1993.
Hammer, Willie. Handbook of System and Product Safety . Englewood Cliffs, NJ: Prentice-Hall, 1972.
Johnson, William G. MORT Safety Assurance Systems . New York: Marcel Dekker, 1980.
Kitfield, James. "Crisis of Conscience". Government Executive Magazine; October 1995, pp. 14-24.
Perrow, Charles. Normal Accidents . New York: Basic Books, 1984.
___ Report to the President by the Presidential Commission on the Space Shuttle Challenger Accident , Volume 1 of 5. Washington: U.S. Government Printing Office, 1986.
Reason, James. Human Error.Cambridge University Press, 1990.
Rogers, William P. Introduction to System Safety Engineering New York: John Wiley, 1971.
Roland, H. E. and B. Moriarty. System Safety Engineering and Management New York: John Wiley, 1983.
Stephenson, Joe. System Safety 2000 . New York: Van Nostrand Reinhold, 1991.
System Safety Analysis Handbook. System, Safety Society, 1993.
Thompson, Mark. "Way, Way Off in the Wild Blue Yonder". Time Magazine, 145:22; May 29, 1995, pp. 32-33.
Vaughan, Diane. The Challenger Launch Decision . University of Chicago Press, 1996.
References cited in a 1991-1992 2-part paper Mishap Investigations: Tools for Evaluating the Quality of System Safety Program Performance decries the lack of research or inquiries into accident investigation quality assurance practices, and proposes a way to validate investigations and their outputs.
-
References for Part 1
Benner, L., Accident Models and Investigation Methodologies employed by Selected U.S. Government Agencies. Report to U.S. Department of Labor, Occupational Safety and Health Administration, Washington, DC. February 21, 1983.
Benner, L., "Accident Theory and Accident Investigation". Proceedings of the Society of Air Safety Investigators Annual Seminar, 1975, p.149.
Johnson, W., MORT Safety Assurance Systems. Marcel Dekker, New York, 1983, p.373.
Rimson, I.J., "Are These the Same Accident?" ISASI forum, Vol.15, #3, 1983, pp.12-13.
Rimson, I.J., 'Standards for the Conduct of Air Safety Investigation". Proceedings of the Twenty-first Annual Seminar, International Society of Air Safety Investigators. ISASI forum, Vol.23, #4, February 1991, pp.51-54.
WaIler, J. A., M.D., "Epidemiologic Approaches to Injury Research". In Rare Event/Accident Research Methodology, Proceedings of a Workshop held at the National Bureau of Standards, May 26-28, 1976. NBS Special Publication 482. U.S. Department of Commerce, Washington, DC, 1977, p.44.
References for Part 2Benner, L., "Accident Theory and Accident Investigation". Proceedings of the Society of Air Safety Investiga-tors Annual Seminar, 1975, p.149.
Benner, L., Accident Models and Investigation Methodologies Employed by Selected US Government Agencies. Report to the Occupational Safety and Health Administration, US Department of Labor. Washington, DC, February 21, 1983.
Benner, L., "Four Accident Investigation Games", Events Analysis, Inc. Oakton, VA, 1976.
Hendrick and Benner, Investigating Accidents with STEP. Marcel Dekker, New York, 1987.
Johnson, W., MORT Safety Assurance Systems. Marcel Dekker, New York, 1980.
Rimson, I. J., "Are These the Same Accident?". ISASI forum, 1983, #3, pp.12-13.
Rimson, I.J., "Standards for the Conduct of Air Safety Investigation". ISASI forum, V.23, #4, p.51
References from a 1995 position paper prepared for FAA Office of System Safety Workshop on Flight Crew Accident and Incident Human Factors Human Factors Intervention Strategies to Prevent Aircraft Accidents: Paradigm Shifts to Exploit Successful Human Factors Interventions for Aircraft Accident Prevention which recommended implementation of new investigation paradigm focused on successful intervention actions by pilots in near miss incidents.
Benner, Ludwig Jr.; Four Accident Investigation Games: Simulations of The Accident Investigation Process. Events Analysis, Inc., Oakton, VA 1979. 2nd Edition 1982
Benner, Ludwig Jr.; Rating Accident Models and Investigation Methodologies." J. Safety Research 16:3, Fall 1985, Chicago, IL.
Benner, Ludwig Jr. & Ira J. Rimson; Quality Management for Accident Investigators". forum 24:3, October 1991 (Part 1); 25:1, March 1992 (Part 2). International Society of Air Safety Investigators (ISASI), Sterling, VA.
Feil, John A. & C. L. Lewis; Accident/Incident Prevention through Airport Safety (An Airline Program for Airfield Inspection and Audits)." forum 23:4, February 1991. ISASI, Sterling, VA.
Ganse, Larry R. Integrating Accident Prevention and Investigation." forum 27:4, December 1994. ISASI, Sterling, VA.
Hendrick, Kingsley & L. Benner, Jr.; Investigating Accidents with STEP. New York, Marcel Dekker, 1987.
Hendrick, Kingsley, L. Benner & R. Lawton; A Methodological Approach to the Search for Indirect Human Elements in Accident Investigations." Proceedings of the Fourth International Symposium on Aviation Psychology. (R. S. Jensen, Ed.) The Ohio State University, Columbus; April 29, 1987.
Lawton, Russell L., L. Benner, R. Clarke, R. Jensen, A. Adrion & J. Maresh; The DECIDE Approach to Training Pilots & Pilot Decision Making. AOPA Air Safety Foundation, Frederick, MD; June 1987.
Perrow, Charles; Normal Accidents. New York, Basic Books, 1984.
Lawton, Russell L., L. Benner, R. Clarke, R. Jensen, A. Adrion & J. Maresh; The DECIDE Approach to Training Pilots & Pilot Decision Making. AOPA Air Safety Foundation, Frederick, MD; June 1987.
Perrow, Charles; Normal Accidents. Rare Event/Accident Research Methodology; NBS Special Publication 482. Washington DC. U.S. Department of Commerce, National Bureau of Standards, 1977.
Ratner, Robert S. & J. Guselli;Techniques for Identifying Indirect Causal Factors in Aviation Incidents and Accidents." forum 28:2, June 1995. ISASI, Sterling, VA
Reason, James T.; Human Error. Cambridge, Cambridge University Press, 1990.
Rimson, Ira J., & J. B. Galipault;Incident Analysis: A Key to Accident Prevention". forum 12:3, Winter 1979. ISASI, Sterling, VA.
Rimson, Ira J.;Standards for the Conduct of Aircraft Accident Investigations". forum 23:4, February 1991. ISASI, Sterling, VA.
These references are from a 1995 paper Preventing Flight Crew Errors: Primary Data Must Drive Analyses which argued that the FAA should get investigations of mishapsturned around" by changing its project goals, approaches
and methods, and propose specific actions, using primary source data for analyses.Benner, Ludwig Jr.; 10 MES Investigation Guides, Ludwig Benner & Associates, Oakton, VA 1979. 2nd Edition 1994
Benner, Ludwig Jr. & Ira J. Rimson; "Quality Management for Accident Investigators". forum 24:3, October 1991 (Part 1); 25:1, March 1992 (Part 2). International Society of Air Safety Investigators (ISASI), Sterling, VA.
Federal Aviation Administration, Office of System Safety, Proceedings of Workshop on Flight Crew Accident and Incident Human Factors, June 21-23, 1995,
Hendrick, Kingsley & L Benner, Jr.; Investigating Accidents with STEP. New York, Marcel Dekker, 1987.
Hendrick, Kingsley, L Benner & R. Lawton; "A Methodological Approach to the Search for Indirect Human Elements in Accident Investigations." Proceedings of the Fourth International Symposium on Aviation Psychology. (R. S. Jensen, Ed.) The Ohio State University, Columbus; April 29, 1987.
Reason, James T.; Human Error. Cambridge University Press, 1990.
Rimson, Ira J.; "Standards for the Conduct of Aircraft Accident Investigations". ISASI forum 23:4, February 1991. ISASI, Sterling, VA.
Vaughan, Diane, THE CHALLENGER LAUNCH DECISION; Risky Technology, Culture and Deviance at MM,. University of Chicago Press, Chicago, IL 1996
Footnotes
See Vaughan, p 8. "Unraveling the history of the decision making.. in its televised hearing, the Commission laid the groundwork for what became the historically accepted explanation of the Challenger launch decision: production pressure and managerial wrongdoing."
Ibid. p 11 for differences between Commission and Committee findings. Neither emphasized technical difficulties in reaching decisions, so public could recognize problems.
Ibid. p 73 about situating controversial actions In the "stream of actions" in which they occurred. See also pp 243-247 for discussion of the decision stream context for examining decisions.
Ibid. p 393. "Retrospection corrects history, altering the past to make it consistent with the present, implying that errors should have been anticipated. " Compare to J. Reason's comments about "falling prey to the fundamental attribution error (blaming people and ignoring situational factors)" and ".the retrospective observer should be aware of the beam of hindsight in his own eye." (Reason) p 216
Ibid. p 393. "Understanding organizational failure depends on ..going beyond secondary sources, relying instead on personal expertise based on original sources that reveal the complexity, the culture of the task environment, and the meanings of actions to insiders at the time."
See 055 1995 Workshop Proceedings, Wise and Wise, A-105 for discussion of a priori questions, in the context of conducting the investigation of decision making.
See 055 1995 Workshop Proceedings, Benner & Rimson, A-21-22. Vaughan's work shows how they might be implemented.
See Benner & Rimson 1992 for example of non-statistical validation of a description of what happened, including decisions and actions by decision makers.
See ethnographic research methods (Vaughan) or STEP (Hendrick and Banner) or events overlays (Hendrick, Benner and Lawton) or multilinear events sequencing methods (Benner 1994) The last provides for "progressive" testing of data as data are acquired during an investigation, to determine data still needed, or sufficiency of explanation of what happened
See OSS 1995 workshop proceedings, p 7 reporting the need for narrative description of events and access with a narrative search capability.
A personal communication with NASDAC staff disclosed that an obstacle to data integration by NASDAC has been inconsistency of terms across reports processed.
References in a 1997 paper SYSTEM SAFETY ANALYSIS PITFALLS identified deficiencies in system safety techniques that create pitfalls for system safety analysts and their consequences.
Miller, C. O., Requirements for a System Safety Programs as Delineated by MIL-STD-882, NASA Government Industry System Safety Conference, Greenbelt, Md. 1971
Hammer, Willie, Handbook of System and Product Safety, Prentice Hall, Inc. Englewood Cliffs, NJ 1972
Brown, D.B., Systems Analysis & Design For Safety, Prentice Hall, Inc. Englewood Cliffs, NJ 1976
Johnson, W.G., MORT Safety Assurance Systems, Marcel Dekker, New York 1980
Malasky, S.W., System Safety: Technology and Application, Garland STPM Press, New York 1982
Department of Defense, MILSTD 882B, 1984
Kayes, P.J. (Ed.), Manual of Industrial Hazard Assessment Techniques, World Bank, Washington, DC 1985
Olson, R. E., System Safety Handbook for the Acquisition Manager, System Safety Society, Littleton, CO undated (est. 1986)
Roland, H.E. and Moriarty, B, System Safety Engineering and Management (2nd Edition),, John Wiley & Sons, New York 1990
System Safety Society, System Safety Analysis Handbook. System Safety Society, Sterling, VA 1993.
. Rimson, I.J. and Benner, L. Mishap Investigation: Tools for Evaluating the Quality of System Safety Programs, Hazard Prevention 33:1 1997. Biography
References cited in a 2003 paper Investigating Investigation Methodologies
Sklet, Snorre, Comparison Of Some Selected Methods For Accident Investigation, NTNU/SINTEF, Trondheim, Norway, 2003
Harvey, Michael D., Models for Accident Investigation, Alberta Worker Health, Safety and Compensation, Alberta, Saskatchewan, 1985
Benner, L., Rating Accident Models And Investigation Methodologies, Journal of Safety Research, 16:3, Fall 1985 Chicago, IL
Henderson, J., Whittington, C and Wright, K., Accident investigation - The drivers, methods and outcomes, HSE Report 344/2001, Human Reliability Associates, 2001
CCPS Center for Chemical Process Safety, Guidelines for Investigating Chemical Process Incidents, American Institute of Chemical Engineers, New York, NY 1992
U.S. Chemical Safety and Hazard Investigation Board, Investigation Report: Thermal Decomposition Incident (3 Killed). Report No. 2001-03-1-GA, June 2002.
Johnson, W. G., MORT Oversight and Risk Tree , SAN 821-2, U. S. Atomic Energy Commission, 1973
Paradis, M. and Unger, L., TapRootR, System Improvements Inc., Knoxville, TN 2000
Benner, L., 10 MES Investigation Guides, Starline Software Ltd., 2002
Benner, L.,10 MES Investigation Guides, Guide 2 Task Guidance For Organizing And Analyzing Investigation Data, Starline Software Ltd. 2002
References from a 2007 paper Accident Data for the Semantic Web describes impediments to learning
lessons from accident investigations, and options for overcoming those impediments.
Johnson, C.W., (1999) Improving the Presentation of Accident Reports over the World Wide Web" Proceedings of the 17th International Systems Safety Conference, The Systems Safety Society, Unionville, Virginia, USA, p 396-405, (http://www.dcs.gla.ac.uk/~johnson/papers/Web_accidents/paper.html)
____(2003) http://www.hss.doe.gov/csa/analysis/ll/sells/faqs/LLinfo.pdf
See Model Minimum Uniform Crash Criteria (MMUCC) project (2003). The purpose of MMUCC is to provide a minimum, standardized data set for describing crashes of motor vehicles that will generate the information necessary to improve highway safety in each state and nationally. (http://www.mmucc.us/index.htm)
Werner, P. and Perry, R., (2004) The Role of Lessons Learned in The Investigate, Communicate, Educate Cycle for Commercial Aviation, System Safety Society Proceedings of the 35th Annual International Gold Coast, Queensland, Australia, August 30’ÄìSeptember 2, 2004, pages 51-56.
United States General Accounting Office (2002) Report to the Subcommittee on Space and Aeronautics, Committee on Science, House of Representatives, NASA: Better Mechanisms Needed for Sharing Lessons Learned, GAO-02195,
See a listing of Lessons Learned Centers at http://call.army.mil/links/lessons.asp
Dien, Y and Llroy, M., (2004) Effects of the Columbia Space Shuttle Accident on High-Risk Industries, or Can we Learn Lessons From Other Industries, presented to ’ÄúHAZARDS XVIII-PROCESS SAFETY-SHARING BEST PRACTICE’Äù 23-25 November 2004, Weston Building, UMIST, Manchester
For an example, see http://www.wildfire lessons.net/Home.aspx (2007)
European Commission Major Accident Reporting System (MARS), serving member states.
ASRS Program Review, Database Search Requests, Search Inquiries by Organization (2005) http://asrs.arc.nasa.gov/briefing/br_26.htm
Kletz, T.A., (2001) Learning from Accidents, Third Edition, Gulf Professional Publishing, Oxford England
Sklet, S. (2003) Comparison of Some Selected Methods for Accident Investigation, JRC ESReDA Seminar on SAFETY INVESTIGATION OF ACCI DENTS, EC DG JRC, Petten, Netherlands 12 May 2003
For example see the European Community Road Accident Database Glossary http://ec.europa.eu/transport/roadsafety_library/care/doc/care_glossary.pdf
See http://www.iprr.org/tools/softw.html for a list of software reviewed (2007)
ASRS Database Online (2007) with reporting and search capabilities accepts .cvs or .xls formatted spreadsheet or tabular input data http://akama.arc.nasa.gov/ASRSDBOnline/QueryWizard_Begin.aspx
For an extensive list of examples of applications in Europe, see XML Applications at Work (2007) at http://www.softwareag.com/xml/dt/default.htm
Neumann, E. K., (2007) Visualizing the Semantic Web, Bio-IT World.com, July-August 2007 ’ÄúWhen working with data, it is just as important to visualize it properly as it is to process it.’Äù
W3C Process Document describing Working Group operation is posted at http://www.w3.org/2005/10/Process-20051014/intro.html
Johnson, C.W. (1999) Improving the Presentation of Accident Reports on the World Wide Web, which argues that image maps, VRML models and QuickTime techniques might be used to improve both the quality and structure of these electronic documents posted by investigation agencies. Emphasis was on documents, not lessons learned. (http://www.dcs.gla.ac.uk/~johnson/papers/Web_accidents/paper.html)
Benner, L. (2002) 10 MES Investigation Guides, Starline Software Ltd, Oakton, VA 22124 http://www.starlinesw.com/product/Guides/MESGuide00.html
References from a 2009 paper Lessons Learning System Attributes: An Analysis describing changes needed to satisfy expectations of lessons learned from accident investigations.
Benner, L (2007) Accident Data for the Semantic Web in: Future Challenges of Accident Investigation, Preprint (Draft) Proceedings of the 33rd ESReDA Seminar, Hosted by JRC, Ispra, Italy, November 13-14, 2007, N. Dechy, G.G.M. Cojazzi, Eds. Office for the Official Publications of the European Communities, Luxemburg, Printed in Italy, 2007.
A retrocursor accident is one which essentially replicates a previous (precursor) accident; the March 23 2009 MD11 crash at Narita and May 31 2008 crane collapse in New York City are examples of retrocursors. (Private communication from I. J. Rimson).
Fielder, J.H. and Birsch, D. (1992) The DC-10 Case: A Study in Applied Ethics, Technology, and Society, ISBN 0791410870, 9780791410875 SUNY Press, Albany NY. History and Early Warnings" section provides extensive discussion of Lessons Learned impediments.
NATO (2006) Final Report Lessons Learned Conference; In NATO-1790-05-JALLCPB-006-06.pdf, Lisbon Portugal 24-26 October 2006, available at http://www.jallc.nato.int/Documents/LLC2006/files/llconfday2.htm
Weber, R.O. and Aha, D. W. (2002) Intelligent Delivery of Military Lessons Learned, in Decision Support Systems, vol. 34 pp 287-304
International Civil Aviation Organization (2001) International Standards and Recommended Practices, Annex 13 Aircraft Accident and Incident Investigation
US Army Center for Army Lesson Learned (2008) CALL Mission, at http://usacac.army.mil/cac2/call/about.asp
- U S Nuclear Regulatory Commission (2002) Accident Investigation Directive 8.9 Washington DC
U S National Aeronautics and Space Administration, (2005) NASA Procedural Requirements NPR 7120.6 Appendix A: Lessons Learned Process Flow, Washington DC
Eaton, J., Redmayne, J. and Thordsen, M. (2006) Joint Analysis Handbook, 2nd Edition NATO Joint Analysis and Lessons Learned Center, Monsanto, Lisbon, Portugal.
Wildland Fire Lessons Learning Center (2008) Background and Operations Brief, Tucson Arizona USA
U S National Transportation Safety Board (2002) National Transportation Safety Board Aviation Investigation Manual Major Team Investigations, Washington DC
U S Department of Energy (1995) Lessons Learned Handbook: DOE-HDBK-7502-95, Figure 3 Lessons Learned Process Flowchart, National Technical Information Service, Springfield VA
Rimson, I.J. (2003) Why Accident Investigations Don't Prevent Accidents Presented at Texas A&M University's Mary Kay O'Connor Process Safety Center Symposium October 29, 2003. Available at http://www.iprr.org/papers/rimsona&mpaper.htm
Coburn, M (2009) The 10-Year Helicopter Accident Reduction Initiative, in AIRBEATMAGAZINE | January February | 2009 p54 describes their use of cause-based methodology to define problems
Cowles, T. R. (2004) Criteria for Lessons Learned (LL), A Presentation for the 4th Annual CMMI Technology Conference and User Group November 15-18, 2004 Abstract #1169
Liebowitz, J. (2008) Knowledge Retention: Strategies and Solutions, CRC Press, ISBN 1420064657, 9781420064650, pp 52-53
Boyd, J. (1986) Patterns of Conflict, p 128; OODA described in original document reproduced at http://www.d-n-i.net/boyd/pdf/poc.pdf. See also OODA LOOP at http://en.wikipedia.org/wiki/OODA_Loop
Kotnour, T. and Kurstedt, H. A. (2000) Understanding the Lessons-Learned Process, International Journal of Cognitive Ergonomics vol 4:4 pp 311-330 ‰Ýevaluating the lesson-learned design parameters."
- Accident Investigation Board of Finland 2007 Annual Report
Donogala, P. (2007) Editorial: 30 years ago ¬‚ Tenerefe. What have we learned? The Controller, Journal of Air Traffic December 2007 p 4
Dekker, SWA 2008 Just culture: who gets to draw the line? Accepted 14 January 2008, Cognition, Technology & Work, DOI 10.1007/s10111-008-0110-7 p 8An incident is a free lessons, a great opportunity to focus attention and learn collectively."
Paradise, M. and Unger, L/ (2000) TapRooT®, System Improvements, Inc., ISBN 1-893130-02-9 p 95 discusses benefits tracking.
U. S. Columbia Accident Investigation Board (2003) Report of Columbia Accident Investigation Board, Volume I, Chapter 8 History as Cause: Challenger and Columbia. http://anon.nasa-global.speedera.net/anon.nasa-global/CAIB/CAIB_lowres_chapter8.pdf
Buncefield Major Incident Investigation Board, (2008) The Buncefield Incident 11 December 2005 The Final Report of the Major Incident Investigation Board, Vol 1. p 21 Item 63 (LL Workshop 20 Dec 07) ISBN 978 0 7176 6270 8
Davis-Besse Reactor Vessel Head Degradation Lessons-Learned Task Force (2002), Davis-Besse Reactor Vessel Head Degradation Lessons-Learned Task Force Report, publicly accessible only at http://www.nrc.gov/reactors/operating/ops-experience/vessel-head-degradation/lessons-learned/lessons-learned-files/lltf-rpt-ml022760172.pdf
UK Department of Transport (2005) Statutory Instruments, 2005 No. 881 MERCHANT SHIPPING The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005
References in a 2013 paper Standardizing Safety Investigation Inputs to Reduce Riskswhich argued that present source data documentation and integration by investigators pose obstacles to better learning from investigations, and reduced risks which could be overcome by exploiting ideas from other domains.
Benner, L., (1980) Accident Investigations: A Case For New Perceptions And Methodologies, Appendix A, Reasons For Investigating Accidents As Reported By Accident Investigators, Society of Automotive Engineers/SP-80/461, Warrendale PA 1980
Benner, L. (1985) Rating Accident Models and Investigation Methodologies, Journal of Safety Research, 16 105-126
Benner, L. (1989) Fire Risks in the Carload and Truckload Transportation of Class A Explosives, Research Report, US Department of Transportation Contract No. DTRS57-88-P-82656. http://www.ludwigbenner.org/Researchdocs/3Pro0j6a.html. Last viewed Sept 8 2013.
Benner, L. (2007) Investigation Catalyst-Preview, Starline Software Ltd, Oakton, VA. Description of investigation support software package and tutorials at http:// www.investigationcatalyst.com/Preview/ICpreview.html. Last viewed Sept 8 2013.
Benner, L. (2010) Transforming Experience into Performance Improvement presented paper at Human Performance Root Cause Trending (HPRCT) Conference, Baltimore MD September 2010.
Benner, L. (2012) Accident Data for the Semantic Web, Safety Science, 50:6, July 2012. Special Edition with papers from 2007 ESReDA seminar in Ispra IT.
Benner, L. (2012a) The Complete Library of Ludwig Benner’Äôs Works, http:// www.ludwigbenner.org. Material describing the system and its implementation are available at the web site, including QA, Task Guidance, Tutorials, Simulations, etc. Last viewed Sept 8 2013.
Forrester, J.W, 1961 Industrial Dynamics, M.I.T. Press Cambridge MA
Hendrick, K. and Benner, L., (1987) Investigating Accidents With Step, Marcel Dekker, New York/Basel. ISBN 0-8247-7510-4. Refined in Benner, L., Guide 2, Task Guidance for Organizing and Analyzing Investigation Data, Starline Software Ltd. Oakton, VA 2003, and further refined during the development of Investigation Catalyst software.
Hollnagel, E. and Speziali , J. (2008) Study on Developments In Accident Investigation Methods: A Survey of the ’ÄúState of the Art’Äù SKI Report 2008:50 ISSN 1104-1374
Jacobs, H. H. et al, (1961) Behavioral Approaches to Accident Research, Association for the Aid of Crippled Children, New York NY
45th ESReDA Seminar, Oporto, Portugal October 23-34 2013
JRC’Äì (2011) Comparative Analysis of Nuclear Event Investigation Methods, Tools and Techniques, Interim Technical Report, EUR 24757 EN
Johnson, W.G., (1972) MORT The Management Oversight and Risk Tree, U. S. Atomic Energy Commission, Contract No. AT (04-3)-821, submitted February 12 1972,
Johnson, W.G. (1972a) Private conversation. His interest in NTSB’Äôs HAR 71-06 Accident Report containing a flow chart of the accident led to its adaptation as Events and Causal Factors Charting for the MORT Safety Assurance System he developed for the US Atomic Energy Commission.
Leontief, W., (1985) Input-Output Economics-2nd Edition, Oxford University Press, ISBN13:9780195035278, Chapter 2.
Rimson, I.J. (2003) Why Accident Investigations Don’Äôt Prevent Accidents, Presented at Texas A&M University’Äôs Mary Kay O’ÄôConnor Process Safety Center Symposium; October 29, 2003
Sklet,S. (2002) Methods for Accident Investigation (ROSS (NTNU) 200208) NTNU Trondheim Norway
Stenge, Peter, (1990) The Fifth Dimension: The Art & Practice of The Learning Organizations, ISBN 0-385-26095-4 Doubleday New York
Taylor, Frederick W., (1911) The Principles of Scientific Management, Harper & Brothers Publishers, New York
Weiner, Norbert, (1965) Cybernetics-2nd Edition, MIT Press Cambridge MA
US JHSAT (2009) final report Calendar Year 2001 Report To The International Helicopter Safety Team September 2009, downloaded at http://www.ihst.org/portals/ 54/2001_Report.pdf September 2013. Also private discussions with team member.
References in a 2015 paper Is It Time To Purge Legal Constructs From Safety Investigations
describing adverse influences of certain legal constructs on safety investigations, and arguing for the purging
those constructs from safety investigations.
Alaska Dispatch News, 2014 NTSB: 'Inadequate safety management' contributed to fatal trooper helicopter crash, November 5, 2014. Last viewed at http://www.adn.com/article/20141105/ntsb- inadequate-safety-management-contributed-fatal-trooper-helicopter-crash Nov 6 2014)
BBC News, 2012 , Concorde crash: Continental Airlines killings verdict quashed. http://www.bbc.co.uk/news/world-europe-20545201
BEA- (2012) Final Report on the accident on 1st June 2009 to the Airbus A330 203 registered FGZCP operated by Air France flight AF 447 Rio de Janero-Paris (EN) Bureau d’ÄôEnqueÃÅtes et Analyses pour la seÃÅcuriteÃÅ de l’Äôaviation, civile, Aeroport du Bourget, France. (4 languages)
Benner, L., (1980) Accident Investigations: A Case For New Perceptions And Methodologies, Society of Automotive Engineers/SP-80/461, Paper 800387, Warrendale PA February 1980
Benner, L., (1980a) Safety’Äôs Hidden Defect: Accident Investigation, slide for presentation of SAE Paper 800387, Society of Automotive Engineers, Warrendale slide 10A February 1980 Last viewed at www.ludwigbenner.org/pap#6FC3C2 Nov 24 2014
Benner, L. (1985) Rating Accident Models and Investigation Methodologies, Journal of Safety Research, 16 105-126
Benner, L. (1989) Fire Risks in the Carload and Truckload Transportation of Class A Explosives, Research Report, US Department of Transportation Contract No. DTRS57-88-P- 82656. Last viewed at http://www.ludwigbenner.org/Researchdocs/3Pro0j6a.html. Nov 14 2014.
Benner, L., (1995) Words Mean Something. This manuscript was the first of a series being prepared for the forum Editor for publication in ISASI forum. Change in forum Editors terminated project. Paper available on line at http://www.ludwigbenner.org/papers/Words.htm
Benner, L. (2007) Investigation Catalyst-Preview, Starline Software Ltd, Oakton, VA. Description of investigation support software package and tutorials at http://www.investigationcatalyst.com/Preview/ICpreview.html. Last viewed Sept 8 2014. See also Tech Notes at this site.
Benner, L. (2010) Transforming Experience into Performance Improvement presented paper at Human Performance Root Cause Trending (HPRCT) Conference, Baltimore MD September 2010. Viewed at http://www.ludwigbenner.org/papers/llset/HPRCT-2010_paper-fin.pdf on Nov 24 2014
Benner, L. (2012) Accident Data for the Semantic Web, Safety Science, 50:6, July 2012. Special Edition with papers from 2007 ESReDA seminar in Ispra IT.
Benner, L. (2012a) The Complete Library of Ludwig Benner’Äôs Works, http://www.ludwigbenner.org. Material describing the system and its implementation are available at this web site, including quality assurance, task guidance, tutorials, simulations, etc. Last viewed Nov 24 2014.
Dekker, S.W.A. (2003) When human error becomes a crime. Human Factors and Aerospace Safety, 3(1), 83-92.
Dekker, S.W.A., (2013) Just culture: who gets to draw the line? Cogn Tech Work DOI 10.1007/s10111-008-0110-7, Viewed at http://sidneydekker.com/wp- content/uploads/2013/01/JustCultureCTW.pdf Nov 3, 2014
Hayakawa, S. I., (1972) Language in Thought and Action (Fourth edition). Harcourt Brace Jovanovich, Inc., New York, NY, 1972, p. 155.
Hendrick, K. and Benner, L., (1987) Investigating Accidents With Step, Marcel Dekker, New York/Basel. ISBN 0-8247-7510-4, p 254-257, 132. Refined in Benner, L., Guide 2, Task Guidance for Organizing and Analyzing Investigation Data, Starline Software Ltd. Oakton, VA 2003, and further refined during the development of Investigation Catalyst software.
Honore, Antony, (2014)Causation in the Law", The Stanford Encyclopedia of Philosophy (Winter 2010 Edition), Edward N. Zalta (ed.), Viewed at http://plato.stanford.edu/archives/win2010/entries/causation-law/ Nov 6 2014
ICAO (2001) Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation, International Civil Aviation Organization (ICAO) Montreal Quebec Canada. 9th Edition. ’ÄúThe causes of an aircraft accident or serious incident must be identified in order to prevent repeated occurrences.’Äù
IPRR (2014) Investigation Process Research Resource Site, Internet site with resources for investigation process investigators http://www.iprr.org.
ISASI 1983 Code of Ethics, §5 (Rev. 10/83) International Society of Air Safety Investigators, Herndon, VA.
ISASI (2014) Seminar Proceedings -1970-2014. International Society of Air Safety Investigators, Herndon, VA. http://www.isasi.or/Library/seminar-proceedings.aspx
Johnson, W. G. (1980) MORT Safety Assurance Systems, ISBN 0-8247-3, Marcel Dekker N.Y. NY, p 353
JRC ’ÄìIE (2011) Comparative Analysis of Nuclear Event Investigation Methods, Tools and Techniques, Interim Technical Report, EUR 24757 EN
MacIntosh, R., (2010) The Accident ’ÄòCAUSE’Äô Statement’ÄîIs It Beyond Its Time? April’ÄìJune 2010 ISASI forum p 5-9
L Benner Jr Page 17 5/7/15
Manuele, F., (2014) Incident Investigation Our Methods Are Flawed, Safety Management, October 2014 p 34-42
Miller, C.O. (1991) Down with Probable Cause, Proceedings of the Twenty-Second International Seminar of the International Society of Air Safety Investigators, Canberra Australia, November 4-7, 1991, p 120-135.
NTSB- (2000) NTSB Petitions For Reconsiderations, Approved 1994-2000 Or Unanswered As Of 5/24/00, National Transportation Safety Board, viewed at http://www.iprr.org/comps/NTSBpfrdb.html
NTSB- (2014)Title: Alaska DPS Helicopter Crash Caused by Flight Into Bad Weather and Department's Punitive Culture, NTSB Press Release, National Transportation Safety Board, Dated November 5 2014. (Vied at http://www.ntsb.gov/news/2014/141105.html on November 6,2014)
Pruchnicki, S., (2014) Plane crash probes should cast wider net, Special to CNN updated 10:44 AM EST, Fri January 10, 2014 Viewed at http://www.cnn.com/2014/01/09/opinion/sole-survivor-shawn-pruchnicki/
Rimson, I.J., (2003) ’ÄúInvestigation ’ÄúCause’Äù and Assigning ’ÄúBlame’Äù, 6th Annual Symposium, Mary Kay O’ÄôConnor Process Safety Center ’ÄúBeyond Regulatory Compliance: Making Safety Second Nature’Äù Reed Arena, Texas A&M University, College Station, Texas October 28-29, 2003. Viewed at http://pscfiles.tamu.edu/symposia/2003/Ira%20Rimson.pdf on Nov 24, 2014
USC -United States Code, (2004) Title 49, Subtitle II, Chapter 11 Subchapter III ¬ß1131(a)(1.) GeneralAuthority ’ÄúThe National Transportation Safety Board shall investigate or have investigated (in detail the Board prescribes) and establish the facts, circumstances, and cause or probable cause of ’Äî[modal accidents]’Äú
USCFR (2015) United States Code of Federal Regulations Title 29, Subtitle B, Chapter XVII, Part 1960, Subpart D, § 1960.29 Accident Investigation
Werner, Dr. Paul & Perry, R, 2005 ’ÄúThe Role of Lessons Learned in the Investigate, Communicate, Educate Cycle for Commercial Aviation.’Äù Presented at the ISASI 2004 Seminar; excerpted in ISASI Forum, V. 38, #4, October-December 2005, pp. 20-25.
Wikipedia (2014) Accident Analysis at http://en.wikipedia.org/wiki/Accident_analysis. This page reflects widespread perceptions of the safety investigation process.
Wood, G.S., 2011The Idea of America, Reflections on the Birth of the United States", The Penguin Press, New York, NY. p 89
References in a 2015 paper What do STAMP-based Analysts Expect from Safety Investigations? examining information CAST analysts require and it sources, and what is available now from investigations.
N.G. Leveson, Engineering A Safer World: Systems Thinking Applied to Safety, MIT Press, Cambridge, MA, 2011.
N.G. Leveson, An STPA Primer, http://sunnyday.mit.edu/STPA-Primer-v0.pdf (accessed 2 September 2015).
IHST, Accident Analysis Process for a Joint Helicopter Safety Analysis Team (JHSAT), third ed., International Helicopter Safety Team, Vancouver, 2012.
MIT Portugal, Akamai, CAST Tutorial - Causal Analysis using System Theory - STAMP approach to accident analysis, STAMP Workshop, MIT, Cambridge, MA, 2013.
S. Ziedelis, M. Noel, Comparative Analysis of Nuclear Event Investigation Methods, Tools and Techniques - Interim Technical Report EUR 24757 EN, European Commission Joint Research Centre ’Äì Institute for Energy, 2011.
J. Stoop, Challenges to the Investigation of Occurrences: Concepts and Confusion, Metaphors, Models and Methods, ESReDA Project Group Dynamic Learning from Accident Investigation, Baden, 2015.
J. F. W. Mohrmann, Investigating Flight Crew Recovery Capabilities from System Failures in Highly Automated Fourth Generation Aircraft, Master Thesis (unpublished), TU Delft, Delft, 2013.
L. Benner, Model of Human Decision Process for Accident Investigators, http://www.ludwigbenner.org/papersa/3humdecn.html (accessed 10 September 2015).
L. Rosenkopf, M.A. Schilling Comparing alliance network structure across industries: observations and explanations Strategic Entrepreneurship Journal, 1 (2007), pp. 191’Äì20
View Record in Scopus | Full Text via CrossRef | Citing articles (47)
H.P. Minsky, Stabilizing an Unstable Economy, Yale University Press, New Haven, CT, 1988.
A. J. Berkhout, The Dynamic Role of Knowledge Innovation, Delft University Press, Delft, 2000.
S.P. Feldman The revolt against cultural authority: Power/knowledge as an assumption in organization theory, Human Relations, 50 (1997), pp. 937’Äì955 View Record in Scopus | Full Text via CrossRef | Citing articles (10)
ESReDA, Case Study Analysis On Dynamic Learning from Accidents: The ESReDA Cube, A Method and Metaphor for Exploring a Learning Space for Safety, ESReDA Project Group Dynamic Learning from Accident Investigation
Section C
This section contains a listing of some other references for investigation process research efforts..
List of 137 Presentations and Publications of significance, by my colleague and friend, the late C O Miller, many of which could be helpful to investigation process researchers, especially the material on system safety applications. Download HTML file. Documents were conveyed to Embry Riddle University (AZ) where they may be accessed.