Crash cause investigator

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Crash cause investigator

Human error can be viewed as a cause or a consequence - the driver caused the error or the driver's error was a consequence of other causal factors.

A crash investigator's view of human error will influence how he or she investigates and reports on crashes. Similarly, an organisation's view of human error will influence how it learns from the crash.

Where human error is seen as a cause, the intuitive solution is to fix the cause - retrain or punish the driver.

Where human error is seen as a consequence, the solution has to be to fix those factors that have shaped or provoked the error.

Productive crash investigation views human error as merely the beginning of the search for causes, not the end.

A blame response is not useful

After a car crash, drivers typically blame other drivers or the driving conditions. Organisations often look for blame firstly in another party and then in their own driver. The approach to crash investigation promoted by this standard requires that we let go of the notion of blame (and fault) and turn our attention to the causes (obvious and hidden) of crashes. Where errors are uncovered there are considered as a consequence of something else. By doing this the organisation:

learns from the event

is better placed to control future risk

has access to better information so it can respond proactively

identifies other business related performance gaps (particularly where errors were related to violations)

is promoting a safety culture

is not faced with the challenge of changing one person's behaviour

A starting point

Element 3.3 Responds to hazards is a useful starting point when studying crashes. Below are the principal crash avoidance criteria from this element. In most cases where a crash occurs, the driver did not perform one or more of these criteria. Crash investigation explores which criteria were absent and then considers what caused that.


				Crash cause investigator

					Human error can be viewed as a cause or a consequence - the driver caused the error or the driver's error was a consequence of other causal factors. A crash investigator's view of human error will influence how he or she investigates and reports on crashes. Similarly, an organisation's view of human error will influence how it learns from the crash. Where human error is seen as a cause, the intuitive solution is to fix the cause - retrain or punish the driver. Where human error is seen as a consequence, the solution has to be to fix those factors that have shaped or provoked the error. Productive crash investigation views human error as merely the beginning of the search for causes, not the end. A blame response is not useful After a car crash, drivers typically blame other drivers or the driving conditions. Organisations often look for blame firstly in another party and then in their own driver. The approach to crash investigation promoted by this standard requires that we let go of the notion of blame (and fault) and turn our attention to the causes (obvious and hidden) of crashes. Where errors are uncovered there are considered as a consequence of something else. By doing this the organisation: learns from the event is better placed to control future risk has access to better information so it can respond proactively identifies other business related performance gaps (particularly where errors were related to violations) is promoting a safety culture is not faced with the challenge of changing one person's behaviour A starting point Element 3.3 Responds to hazards is a useful starting point when studying crashes. Below are the principal crash avoidance criteria from this element. In most cases where a crash occurs, the driver did not perform one or more of these criteria. Crash investigation explores which criteria were absent and then considers what caused that.

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Crash cause investigator

The standard

Using the standard