The psychology of accident investigation: epistemological, preventive, moral and existential meaning-making

This 2014 paper from Sid Dekker may interest you.

Sid argues that accident investigations serve different purposes – epistemological, preventative, moral and existential.

This isn’t a light read – you may want a coffee.

Some points:

• As noted in image 2, each purpose has a different aim or impact; epistemological is about explaining what happened and preventative about explaining how to avoid a recurrence; both rather ‘obvious’ aims of investigations
• Investigations, though, whether explicit and/or intentional, can also take on moralistic stances (explaining deviance), and existential (explaining suffering)
• Investigations (particularly from major accidents) are a process of political sensemaking, being an “exercise in power”, involving different actors and agencies with competing interests
• As per image 2, two investigations of the same accident “produced radically different conclusions”

• Moreover, “Political agendas in accident investigation are pursued by omitting, marginalising and selectively highlighting

• ‘Thicker’ descriptions in investigations are argued to be perhaps necessary, because “When we choose words and construct plots to order an accident history, we give the crowded past and disordered chronology an order and a unity that neither the ‘facts’ nor the past possessed”
• Further, “Our words bring facts into being (e.g. ‘the pilots’ failure to. . .’); our choices of where to look and what to call it create the epistemological world, the object of our accident investigation”

• Epistemological purposes are “the most obvious”, often based on an assumption to factually and accurately establish what happened, where a good account is “accurate, plausible, and exhaustive: it accounts for all the facts, and explains which causes were responsible”
• Or, “ so the Cartesian-Newtonian world view would have us believe”, and in an increasingly complex world, these ‘good’ epistemological accounts are “no longer so obvious”
• For instance, effects in a complex system “emerge from the interaction between a multitude of different parts (which is often the normal work of what is seen by everyone as a normal system), rather than that they result from the (mal-)functioning of a single part”
• “Also, a ‘good’ epistemology in complexity does not mean a single narrative”

• Moral purposes also try to establish clear boundaries and around transgressions. Hence, “What seems to be offered here is not just a vocabulary of facts, findings, causes and effects. It is, rather, a vocabulary of moral allusion (e.g., to professionalism), denunciation (e.g., “deviation” and “poor airmanship”) and instructions to others (e.g., prepare for an emergency landing in a timely manner).
• This seemingly technical vocabulary is “dressed up as epistemological too”

For lessons, two suggestions are:

• “We should desist from seeking the meaning of suffering in the past, in explanatory variables. We should locate it in the future, in change variables”
• “We should seek solace not in trite (and surely false) assurances that ‘this will never happen again,’ but in an understanding that error and failure are inevitable by-products of pursuing success in a resource-constrained, goal-conflicted world”

It’s argued that “Accident investigation has a societal license to distort a messy aftermath into clarity”.

Ref: Dekker, S. W. (2015). The psychology of accident investigation: epistemological, preventive, moral and existential meaning-making. Theoretical Issues in Ergonomics Science, 16(3), 202-213.

Study link: https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=651a8dd8660178b9e987c2a32fb8b888f8323fa4

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