Hi all,
I’ve become increasingly interested in accident investigation and are starting to shifting my focus a bit to learn more about it. There must be some of you who are working with, or have been working with this in the forum. I’m looking for books and other resources on how investigations are done etc. Does anyone have any good suggestions?
Great thread. I don’t have any suggestions but would like to benefit from the list of resources provided by any other contributer
In any accident, there is always one person who knows the root cause. The trick is to find him and convince him to sing.
I have always found it useful to interview all crew of a vessel. Nuggets of information can come from the unlikeliest of sources.
Start with getting “Deepwater Horizon A Systems Analysis of the Macondo Disaster” by gcaptain contributor @Earl_Boebert1 and James Blossom. Read the introduction especially the Our Approach section to get an idea of one way to look at things. Of course the book is worth a lot more than just the reference to the approach used.
You can also use the search function to find some threads here where this book and the DWH case was discussed in depth and references were made to other papers and books on this subject. Namely Leveson - you could search on that name as well and maybe come up with other references in those threads.
I went through this training https://www.cgerisk.com/knowledgebase/TOP-SET at TOI and found it to be very useful system. Especially drawing the distinction between gathering information and analyzing information or drawing conclusions. I’m sure you’ve run into investigators come aboard and they are formulating opinions even before they finish gathering information. This system frowns on that approach but I never saw them follow it strictly so as usual what good is a system if you don’t use it.
I’ll reinforce what KPChief said and add a bit. There is a theoretical and a practical aspect to investigation, where the theory argues how it should be done and the practical documents how it is done.
For the theoretical stuff, I definitely recommend reading Prof. Nancy Leveson’s stuff. A slightly earlier draft of her book is available free on her site:
As well as a ton of other material. Coming from (I assume) a maritime background I would especially recommend one of her students’ analysis of the Sewol-ho ferry accident in South Korea. It’s a gut-wrenching read:
http://sunnyday.mit.edu/papers/Kwon-Thesis.pdf
For the practical side, I’d recommend picking an accident of interest and going to the NTSB docket site:
https://www.ntsb.gov/investigations/SitePages/dms.aspx
and searching for the docket. Don’t just read the final report: go through the docket and read the intermediate reports and the testimony. Then decide how you would have put together the final report.
Cheers,
Earl
The NZ transport investigation of the MV Rena was a thorough job. If you want to see a report truly atrocious in its construction, read the Italian investigation report on the Costa Concordia.
I’m from Scandinavia and read most of the reports from the Swedish and Danish investigation boards. Could probably request copies of the same kind of information due to public information laws. But to have a public searchable database like this, wow, thats just an amazing resource. Thanks!
Thanks. Another really atrocious investigation is the one on the ferry Estonia, which sank in the Baltic mid 90s. Reading up on how the investigation was held is quite an amazing read.
Both the book by Nancy Leveson and the one recommended by @KPChief seems interesting. Will take a look on both.
There is a very interesting book written by Capt. Messer-Bookman called “Maritime Casualties: Causes and Consequences”. It covers the last hundred years or so of maritime accidents and explains all the changes in regulations and regulatory thinking resulting from individual casualties.