Accident modelling: from symptom to system

A series of surveys on accident investigation model s show a wide variety of models, dedicated to specific industrial applications, doma ins and investigation aspects. In particular the investigation of human factors is ex posed to a wide diversity of models. In reviewing such models, the majority prov es to be a derivate from the Reason’s Swiss Cheese causation model or the Rasmussen model on system hierarchy. Most of the models origin from the proce ss industry and the energy sector. Application in the aviation industry has revealed t heir conceptual limitations. Due to their simplifications and lay interpretations, thei r intervention potential in practice is limited to linear solutions. In order to cope with socio-technological interactions in a multi-actor perspective, a full systems engineering design approach should be applied in a mission specific operating envelope. S uch an approach is submitted to three paradigmatic shifts in investigation methodol ogy. First; disengagement is required between event modelling and systems modelling. Second; a distinction in two design classes is required. A distinction is ma de between linear interventions within the existing design envelope and second orde r interventions focusing on expansion of the design solution space. Third; desi gning safer solutions in a multiactor systems environment requires prototyping, vir tual system model simulation and testing of limit state scenarios. Based on these co nstraints, a framework for safety enhancement is described, derived from experiences in the aviation industry itself. This framework is based on a new view on human error, a dynamic systems engineering design approach, analytical forensic ab ilities and institutional conditions for independent and qualified accident investigatio ns. Accidents and causation