Proving properties of accidents

Johnson, Chris

doi:10.1016/s0951-8320(99)00066-6

Cited by 20 publications

(5 citation statements)

References 11 publications

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“…This has been claimed by several researchers and practitioners (Johnson, 2000;Maurino et al, 1995;Moshansky, 1992;Stoop, 2002). However, Johnson (2001) claims that this potential is not fully explored because accident investigations are so comprehensive that it is impossible for practitioners to interpret the connections between change recommendations (conclusions) and the accident evidence.…”

Section: The Theoretical Presumptionsmentioning

confidence: 62%

Organizational effects of experience from accidents. Learning in the aftermath of the Tretten and Åsta train accidents

Braut

Solberg²,

Njå

2014

Transportation Research Part A: Policy and Practice

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a b s t r a c tThis article explores possible signs on learning in organizations following two major railway accidents in Norway, the Tretten accident in 1975 and the Åsta accident in 2000. These are the most serious railway accidents to have occurred in the past decades and both involved collisions on a single track system. The two events have been analyzed and compared in order to investigate possible learning effects and possible differences in learning given the 25-year span between them. The study is based on the analysis of selected documents related to the accidents in general and the narrative components in the documentation related to learning in particular.Our findings indicate that learning from these events was not expressed as an explicit goal in the aftermath. Learning in these cases seems to be linked for a large part to a change in measures, technical, operational and organizational, but we have not observed any managed confirmation or comprehension processes. The Tretten accident report suggests that the possibility of human error should be mitigated through the implementation of technological barriers, while it omits all other elaborations and risk reducing measures. The Åsta accident report recommended that the work to introduce modern safety management principles that had already been initiated before the accident should be continued. Neither of the accidents yielded any new insights and the knowledge brought forward was merely perceived as confirmation of already-agreed changes.

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Section: The Theoretical Presumptionsmentioning

confidence: 62%

Organizational effects of experience from accidents. Learning in the aftermath of the Tretten and Åsta train accidents

Braut

Solberg²,

Njå

2014

Transportation Research Part A: Policy and Practice

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“…Empirical case studies [22,27] have identified the difficulties when text was the only medium available for communicating security lessons. Similar difficulties were identified in safety area, when text was the only approach for expressing complex safety arguments [45]. The free-style text is considered to be unclear and not well structured, the meaning of the text, and therefore the structure of the safety argument, can be ambiguous and unclear [30].…”

Section: Lessons Learned Sharing Using Diagramsmentioning

confidence: 97%

Security Assurance Modelling of Security Incident in Healthcare using the Generic Security Template (GST)

Luo

2020

Preprint

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Background: The recent industry reports show that the number of security incidents in healthcare sector is still increasing, especially the high severity incident, such as data leakage incident and ransomware, which can lead to significant impact on healthcare services. It is imperative for the organizations to learn lessons from those incidents. Traditional ways to disseminate lessons learned are based on text approach, the linear format of which can obscure relationships among concepts and discourage readers from integrating information across ideas. Graphical diagrams can serve this purpose, as it can communicate both individual elements of information and relationships between them. Methods: The Generic Security Template (GST) has been proposed to support the exchange of lessons learned from security incidents. It utilises graphical notations to communicate both individual elements of information and relationships between them. This paper conducts a case study by adopting the GST to capture and structure the incident information of a data leakage incident in a UK healthcare organization in order to facilitate incident exchange. Results: The results show that, the GST was able to visualise and depict the key elements, including lessons learned, the associated security requirements and organizational contextual information identified from the selected data leakage incident case study from NHS. GST provides a unified way to communicate incident information. Conclusions: This research has significance for the healthcare organizations to improve their incident learning practices. It fosters an environment where different stakeholders can speak the same language while exchanging the lessons learned from the security incidents. Future work will consider apply the GST to analyse other complex security incidents such as the advanced persistent threats (APTs) in healthcare organizations and extend the use of the GST in other industries. Keywords: Security Assurance Modelling, Generic Security Template (GST), Security Incident, Healthcare Organization.

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“…Some reports specify only the roles (e.g., the NTSB discusses the causes in terms of "pilot" or "co-pilot"). Johnson [36] describes the ambiguity that many accident reports contain because they use inconsistent natural language. When reports did not specify names or roles, we inferred the roles.…”

Section: Plos Onementioning

confidence: 99%

Preventing slips, overruns, and cancellations: Application of system accident investigations and theory to the understanding and prevention of engineering project failures

Aloisio

Marais

2020

PLoS ONE

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Organizations that develop or operate complex engineering systems are plagued by systems engineering failures like schedule overruns, budget exceedances, and project cancellations. Unfortunately, there is not much actionable guidance on why these failures happen or how to prevent them. Our approach contains two novel aspects. First, we argue that system accidents and other failures in systems engineering are manifestations of similar underlying problems. Therefore, we can leverage the literature on accident causation and the many publicly available accident investigation reports to better understand how and why failures in systems engineering occur, and to identify ways of preventing them. Second, to address the lack of concrete guidance on identifying and preventing incipient failures, we provide specific examples of each type of failure cause and of the recommendations for preventing these causes. We analyzed a set of 30 accidents and 33 project failures, spanning a range of industries, and found 23 different failure causes, most of which appear in both accidents and other project failures, suggesting that accidents and project failures do happen in similar was. We also identified 16 different recommended remedial actions. We link these causes and recommendations in a cause-recommendation network, and associate over 900 specific examples of how these causes manifested in failures, and over 600 specific examples of the associated recommended remedial actions, with each cause or recommendation.

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Proving properties of accidents

Cited by 20 publications

References 11 publications

Organizational effects of experience from accidents. Learning in the aftermath of the Tretten and Åsta train accidents

Organizational effects of experience from accidents. Learning in the aftermath of the Tretten and Åsta train accidents

Security Assurance Modelling of Security Incident in Healthcare using the Generic Security Template (GST)

Preventing slips, overruns, and cancellations: Application of system accident investigations and theory to the understanding and prevention of engineering project failures

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