This inquiry investigated legal constructs that have been adopted by or adapted for safety investigations, and their influences on safety investigation practices, work products, and uses. After such legal constructs were identified, their observed or reported influences were documented. Some of those legal constructs were found to have discernibly detrimental influences on safety investigations, their outputs or uses. Those consequences seem to justify purging them from safety investigation constructs and practices. The report suggests possible approaches for purging those detrimental legal constructs from safety investigation practices.
Safety investigations are undertaken primarily to address societal and operational desires to improve safety by preventing unintended accidental occurrences. Users ranging from individuals to large organizations, each with different purposes, utilize safety investigation work products. Observations of some unusual aspects of these processes motivated this inquiry.
1.1. Motivations for inquiry.
This inquiry was motivated in part by observations of investigations of two aviation accidents involving both safety and judicial entities. (TWA 800, Air France 4590) In the TWA 800 crash, conflicting witness reports raised questions about whether the crash was an accident or willful destruction, and who would do the investigating. In the AF 4590 crash, the safety and judicial investigations resulted in different outcomes. (BEA 2012, BBC 2012) Additional motivating observations included the amount of legal actions following accidents, the continuing discord among safety, judicial and media entities about the use of safety investigation information developed during safety investigations, (BBC 2012) the duplication of investigations indicated by the number of requests for reconsideration of safety investigation reports published by the National Transportation Safety Board, which has a reputation as a superior accident investigation entity, (NTSB 2000) the unsuccessful results of a study that attempted to replicate accident descriptions from published accident reports and find potential recommendations that might have been overlooked (Benner 1989) and reported impediments to learning lessons from accidents.(Werner 2005, Benner 2007) This inquiry was initiated to determine if and how adopted or adapted legal constructs might be influencing these issues, and if they had adverse effects, identify potential replacements
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