Organisational accidents investigation methodology and lessons learned.
The purpose of this paper is to reflect on accident analysis methods. As the understanding of industrial accidents and incidents has evolved, they are no longer considered as the sole product of human and/or technical failures but also as originating in an unfavourable organisational context. After presenting some theoretical developments which are responsible for this evolution, we will propose two examples of organisational accidents and incidents. We will then present some properties of organisational accidents, and we will focus on some "accident-generating" organisational factors. The definition of these factors comes from an empirical approach to event analysis. Finally, we will briefly present their implications for accident and incident analysis.
Dien
Yves
Y
Départment MRI, Electricité de France, Recherche et Développement, 1 Avenue du General de Gavlle, Clamart 92140, France. yves.dien@edf.fr
Llory
Michel
M
Montmayeul
René
R
D000062:Accidents, Occupational / Q000517:prevention & control*; D015984:Causality; D006801:Humans; D008131:London; D017146:Models, Organizational; D009820:Ohio; D015279:Organizational Culture; D018788:Radioactive Hazard Release / Q000517:prevention & control; D011890:Railroads; D017751:Safety Management / Q000379:methods*