Major aviation accident investigations conducted by the National Transportation Safety Board involve uncertainties in cause, complexities in avenues of inquiry, multiple stakeholders, and no obvious solution path. As a result, investigations can be difficult, time consuming, and resource intensive. This paper will describe a project being conducted at NTSB to develop an approach to accident investigation that takes into consideration the complexities, uncertainties, and nonlinearities in accident investigation. The paper concludes by discussing the implications of this approach for the typical linear, structured approaches to accident investigation.
Get full access to this article
View all access options for this article.
References
1.
ConklinJ. (2006). Wicked problems and social complexity. In Dialogue Mapping: Building Shared Understanding of Wicked Problems (New York: John Wiley & Sons).
2.
DekkerS. W.A (2005). Ten Questions About Human Error (Mahwah, NJ: Lawrence Erlbaum).
3.
LevesonN. G. (2004). A new accident model for engineering safer systems. Safety Science, 42 (4), 237–270.
4.
National Transportation Safety Board (2004), Aircraft Accident Report NTSB/AAR-04/04. In-flight Separation of Vertical Stabilizer, American Airlines flight 587, Airbus Industrie A300–605R, N14053, Belle Harbor, New York, November 12, 2001 (Washington, DC: NTSB.
5.
ReasonJ. (1990). Human Error (New York: Cambridge University Press).
6.
RitcheyT. (2006). Problem structuring using computer-aided morphological analysis. Journal of the Operational Society, 57, 792–801.
7.
RittelH.WebberM. (1973). Dilemmas in a general theory of planning. Policy Science, 4, 155–169.
8.
WalkerM. B. (2007). Improving the quality of investigation analysis. ISASI Forum, January-March 2007, 10–13 & 29.
