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Launched Aug 26 1996.
Project Posted 2 Jan 98
This model flow charts the general human decision process elements involved in accidents. Accidents are aborted when the decision maker or object redirects the process to the no-accident outcome. The model was developed by consolidating observations during interviews with accident investigation witnesses. Guidance for applying the model in investigations follows the model.
Source: FOUR ACCIDENT INVESTIGATION GAMES, Appendix V-F, Lufred Industries (now Ludwig Benner & Associates) Oakton, VA 1982
Source: This discussion is adapted from INTRODUCTION TO INVESTIGATION, (1997) Fire Protection Publications, Oklahoma State University, Stillwell, OK. USA
This Model describes the general decision making process faced by people while interactions are occurring among people and objects during any kind of process. The model helps investigators discover and define changes, signals them emit; their detection, communication, and diagnosis; decisions required during the process, and the outcomes of those decisions.
By investigating effects of supervision, training, design, procedures, supervisory direction, and other programmer input sources related to each of these elements, investigators can link specific prior actions or "human factors" to each element.
This tracking of each decision process element enables investigators to define specific relationships among actions as problems or needs. It then enables investigators to pinpoint the places to look for concrete actions (behaviors) that will change future performance, rather than describing problems and needs in subjective, ambiguous or abstract "human factors" terms such as errors, failures, causes, malfunctions, vigilance, attention, wrong, unsafe, skill errors, latent failures, active failures, etc.
To apply this Model during investigations or interviews, identify people who appear to have had a role in the incident process. Then begin to look for changes in the process or its environment that would have created an original need for action by some person (or object) to keep the process progressing toward its intended outcome. Then follow the same process for subsequent changes unto the incident is understood and explained.
After working with this model, investigators are in a much better position to describe and explain what happened when a so-called "human error" or"failure" is alleged. You will also be in a better position to identify concrete actions to improve future behaviors and performance of that system.
Contact: Ludwig Benner, acting Principal Investigator, Ludwig Benner & Associates firstname.lastname@example.org