Glossary of Data Variables for Fatal and accident causation ... - ERSO

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Manual For SafetyNet accident causation system (SNACS) Furthermore, the CSE framework puts forth certain axioms for human behaviour that somewhat diverge from the classical view of the human component in human machine systems. These axioms can be summarized as follows: • Behaviour is meaningful in relation to goals rather than structures • Behaviour takes place in, and depends on, a context • Behaviour is proactive as well as reactive • Behaviour is often automated and unconscious • Behaviour always involves an act of balance between efficiency and thoroughness (safety) – the Efficiency Thoroughness Tradeoff (ETTO) Principle • Meaningful behaviour is the same thing as the ability to maintain control For a deeper dive into why this is a change of perspective in reference to the classical view, see Hollnagels book “Barriers and Accident Prevention”. Looking at the wider perspective, the accident model for SNACS comes from work in industrial safety. It is built from an MTO perspective (Man, Technology, Organisation), and in essence it says that accidents happen when the dynamic interplay between human, technology and organisations is flawed in one or more ways. For road traffic, this means that the human factor is always seen in the larger context of the vehicle and the traffic environment, including the organisations that are responsible for shaping the vehicle and the traffic environment. From the MTO-perspective, there is therefore very rarely a one-toone relationship between cause and effect in an accident sequence. Instead, several coexisting factors are usually contributing to the development of the accident. When analysing the contributing factors, the accident model makes a distinction between factors ”at the sharp end” and factors ”at the blunt end”. ”At the sharp end” is the humans which are interacting with the system(s) in real time, i.e. drivers. When something happens ”at the sharp end”, for instance, two cars collide, it is called a ”sharp end failure”. When trying to find the factors which brought such a ”sharp end failure” about, it is not sufficient to only look at the local circumstances in time and place, i.e. what happened “then and there”. It is necessary to expand the search to also include factors which have contributed in the sense that they have shaped the context in which the accident event took place. These factors are caused by events ”at the blunt end”, i.e. events that can be remote in space and time, but which nonetheless shape the conditions for what happens ”at the sharp end”. If there is a failure ”at the blunt end”, and the consequences of that failure are not discovered and remedied, the consequences will remain in the system as so called ”latent conditions”. These ”latent conditions” can then, together with different dysfunctional behaviours ”at the sharp end”, create accident sequences. The whole accident model can be illustrated as follows: Page 118 of 215
Manual For SafetyNet accident causation system (SNACS) Contemporary accident model Latent conditions “Blunt end” failure “Sharp end” failure Recovery by driver Compensation by vehicle Accident Latent conditions © Erik Hollnagel, 2004 Figure 2: Contemporary Accident Model (Hollnagel, 2004) The point with an MTO-based accident model is that it allows for an accident analysis which not only covers the immediate situation, but also the factors which have shaped the context in which the immediate situation takes place, i.e. which ”latent conditions” are present, and which ” blunt end failures” brought them about. It also allows for the set of possible contributing factors to cover the whole MTO-spectra of Man (driver and shapers of the driving conditions), Technology (vehicle and makers of vehicles) and the Organisation (traffic environment and shapers of traffic environments). Page 119 of 215
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