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Launched Aug 26 1996.

WELCOME to the IPRR site.

Check the Site Guide (above) for an quick overview. L Benner

• A new simple personal Mishap Description Quality Analyzer tool kit is now published and on line. It is used to evaluate descriptions of what happened and why it happened as reported in investigation reports. Its design enables individuals to assess the qulity of reported descriptions of occurrences in which they might have been involved or have a personal interest These open source tools include a User Manual, Tutorial, and MS Word template files - no extra software is required. The tools can be viewed and downloaded at ludwigbenner.org/MDQA/MDQA-kit.html. (Jan 2013)
  

• Eric Hollnagel has published a new book presenting some new resilience-based ideas about safety and accident analysis called "FRAM-The Functional Resonance Accident Model" (Ashgate)that I will try to review in the near future. It adds another kind of accident model to the growing list of models. (Dec 2012)
  

• Announcement: Works authored or coauthored by Ludwig Benner have been collected and are now posted in one place at http://www.ludwigbenner.org. The site is contains over 400 files, ranging from archive lists, books, papers, reports, presentations, unpublished works, reference lists, and transcript excerpts, couse outlines, abstracts, etc., to selected memorabilita, from 1962 to 2012. (Oct 2012)
  
  Starline Software has acted to make all materials referenced on its web site available free to the public under the terms of a GNU General Public License, v3. View site coppyright notice. View GNU Copyright terms. (August 2012)

• A Special Issue of Safety Science (Future challenges of accident investigation Volume 50, Issue 6, 2012) contains selected papers from the ISPRA meeting of ESReDA that could be of interest to accident process researchers.(July 2012)

• There seems to be some activity in Europe to establish ISO/EC standards for Root Cause investigations. It's unclear whether this could lead to investigator certification in the future.(May 2012)

• The Joint Research Center of the Institute for the Protection and Security of Citizens , Ispra, Italy published the document "Future Challenges of Accident Investigation, Proceedings of the 33rd ESReDA Seminar Hosted by JRC, Ispra Italy, November 13-14, 2007," EUR24484 EN, with 21 informative papers for the scientific community. ESReDA is European Safety, Reliability and Data Association (http//www.esreda.org). (October 2011)

• Leveson has posted a draft of her forthcoming book "Engineering a Safer World" on line. It challenges current assumptions about "safety," and offers an extensive discussion of her ideas for getting to a safer world. Considerable content about her views of accident analysis (investigations). Work heavily weighted toward a control approach and tools.Worth reading. (Aug 2011).

• Redefinition of Accident Investigation purposes. The papers in the Investigation Lessons Learning research package effectively redefine accident investigation purposes and investigation process research needs. Viewing and analyzing investigation processes from the perspective of specific end user actions, rather than investigators' or analysts' perspectives, leads to a new investigation purpose: to produce investigation outputs that directly support actual risk-reduction decision and implementation actions with minimal interpretation. This replaces traditional accident causation models and cause determination objectives, and offers new behavioral change perspectives and metrics for accident prevention efforts. That impacts what investigators should do and produce.(November 2010)
  

• A paper and presentation "Transforming Experience Data into Improved Performance"to the 16th Human Performance Rood Cause Trending conference, Baltimore MD, describing shortest route from incident data generation to improved performance, with incremental implementation suggestions, are available for downloading from http://www.iprr.org/research/llprojcontents.html (Items 12 or 13) (June 2010).

• A presentation to the Association of Crime Scene Reconstruction, looking at the potential transfer of accident investigation technology to that field, is now available here (Mar 2010).

• PLEASE NOTE. I continue to see misrepresentations of the MES investigation system and its use in the documents referencing MES, which constrain its use as a valuable investigation system. Part of this problem may be due to the absorption of STEP into MES. To try to remedy misunderstandings, misrepresentations and misuse of MES, a Brochure describing MES, its origins and operation is posted here. View brochure. Additionally, the TechNotes section of the Investigation Catalyst web site provides recent updates about technical misperceptions and issues precipitated by recent papers. Help menus , tutorials and Guides in the Investigation Catalyst software package provide details about the MES system, so there is no excuse for future misuse or misrepresentations of MES in future papers. (Jan 2010)

• A NEW SECTION containing a package of recent Investigation Lessons Learning research documents has been created at this site. It contains abstracts, papers, slide presentations, scripts, two tutorials and a list of noteworthy new insights gained during the research.(Nov 09)

• OPEN SOURCE SOFTWARE UPLOADED.
  Recent research has disclosed a pressing need for structuring accident and incident investigation input data to enable improvements in lessons learning systems performance. To accelerate the development of the needed input data structure, Starline Software Ltd has donated an Open Source (LGPL) library containing source code for structuring stand-alone investigation input data, a sample of code for preparing graphic, tabular and narrative outputs from that data, and the license with the terms for anyone wishing to use the code. The Library is available http:///code.google.com/meslib For more information about this publicly available source code and potential uses, visit meslib site and the Investigation Catalyst web site at www.investigationcatalyst.com (Aug 09)

• I have posted the latest "Outside the Lines" column in the series published in the Journal of System Safety since 2005. (Apr 09)
  

• An increasing number of "safety teams" with acronyms like CAST, IHST, JHSAT, EGAST,and EHSAT are reviewing accident reports to find opportunities for safety recommendations in the aviation community. See an example of an analysis guide at Accident Analysis Process for a Joint Helicopter Safety Analysis Team (JHSAT) at http://www.ihst.org/Default.aspx?tabid=1797&language=en-US Why don't the original accident investigation reports provide the accident information being generated by the HSAT team? (Mar 09)
  

• In a first for this web site, I am recommending that anyone engaged in investigation process research read a recent book by Sidney Dekker "10 Questions about Human Error" (ISBN 0 8058 4744 8 2005) to help you better understand the challenges facing investigators trying to get valid new human factors knowledge from investigations. If you view investigations as a form of research project, as I view them, the Chapter discussing predictive challenges of human error research will be of keen interest. Feb 08
  

• A list of investigation support software I know about is now posted at Tools>Software. Please let me know about any others I have missed, or any mischaracterizations I have shown. 4/07
  

• There's now a Tutorial posted to accompany the Investigation Quality Assurance papers that were posted earlier at this site. The tutorial can be accessed from the papers. 2/07
  

• See previous News posted here at News Archives .

Material posted here is not necessarily endorsed by this site. The page coding is copyrighted, and is now available free under the terms of a GNU General Public License. View Copyright

If you use or download any material from this site, please reference this site as the source, and honor copyrights.

NOTE: This site does not engage in, support or report on "ACCIDENT CAUSATION RESEARCH" )