A first step towards the integration of accident reports and constructive design documents
Abstract
Accident reports are intended to explain the causes of human error and system failure. They are based upon the evidence of many different teams of experts and are, typically, the result of a lengthy investigation process. They are important documents from an engineering perspective because they guide the intervention of regulatory authorities who must reduce the impact and frequency of system 'failures' and human 'error'. There are, however, a number of problems with current practice. In particular, there are no established techniques for using previous findings about human 'error' and systems 'failure' to inform subsequent design. This paper, therefore, shows how extensions to design rationale and contextual task analysis techniques can be used to avoid the weaknesses of existing accident reports.