Three analytical traps in accident investigation

In this video Dr. Johan Bergström introduces how the US NTSB investigation into the accident of Asiana 214 falls into the following three analytical traps:

1: Counterfactual reasoning
2: Normative language
3: Mechanistic reasoning

For those who stand to watch the entire video, there will be a bonus trap at the end of the video :)

[darrenstraker]

The processes explained here are fundamental to the analysis process and forming reasoned arguments for the investigative process.
Opinions, bias and obvious conflicts of interest are additional traps to negotiate. formed, reason arguments particularly as an IIC on major investigation avoids conflict
The accident final reports are consensus documents in accordance with the comments process in ICAO Annex 13; the language of consensus is tame.
There are exceptions, the BEA are effective at communicating their message and recently the Norwegians dropped the facade of normative language and went for EASA and Airbus over a helicopter accident that should not have occurred.
There's a 4th trap, and that's Logical Fallacies. Either-way, these are well constructed and informative videos which highlight the logic and reason required to form objective rationale.

[antifragility]

Very informative videos. I am hopeful that more will be posted. Well done.

[tensortab]

Where are the new videos? I've been reading Woods, Hollnagel and Dekkar, but the safety industry is still talking behavior, swiss cheese and pyramids.

[randyhorwitz]

I try to watch this often when I'm in the midst of an investigation.

[LanceCampeau]

Very interesting... but I'd like to suggest that a portion of these reports are worded specifically for consumption by the general public and living victims for the event. When it comes to assigning blame for a large scale human tragedy there are often political and economic elements that cloud the investigative process.

[scarroll]

It would have helped me better understand why these are traps and are bad if you'd have spent an equal amount of time illustrating some example alternatives to the passages criticized. Much of the language and approach in the example report are typical in air crash investigations.

[coreym]

I'm pretty sure there's a hole in the logic of this presentation. Either you missed the definition of the list (for any number of reasons) therefore possibly impeding your ability to explain how it works or (quite possibly) the FAA "Analytical list of traps" guidelines are flawed. Bold statements? Yes! However, we'll stick to the logic in this presentation in this rant. I am going to have to read the official FAA guidelines before going for them. Correct me if I'm wrong. Anyway, here's how. Assuming a system or person is either right or wrong without knowing personally (before investigation) and not being capable of finding who or what's really responsible after documentation (after investigation and reading the safety guidelines as they currently stand) is observed, renders the entire judgment process, null and void. Impotent. Who decides what the real factors are involved, if no one or nothing is responsible or not under these presented guidelines? The problem isn't what works and was done successfully, it's what didn't and wasn't successful. We're talking about lives here. The Passengers living due to what was done right isn't a factor. Especially, if it's mentioned about what was, wasn't, could, couldn't should and shouldn't have been done in the report. That's all that can be possibly known and surves as a guideline in itself. For experts to rehash a known, predictable, documented system after knowing what worked or not from the investigation is counterproductive and further complicates investigation, communication and resolution and costs lives. Logic is a very rare dicipline these days that most will not follow. Humans aren't so predictable because, of this. A lot of this just sounds like preventing hurting someone's feelings for using apparent terminologies for apparent facts. Feelings never saved lives. Ended them more than not. Empirical and Deductive Reasoning are all you need.

[cdrv]

You are skipping issues related to the investigative process in the US. The NTSB is charged with finding a single cause of an accident. This makes them deal with accidents in a specific manner. We all know that most accidents are caused by multiple factors. You focused on the language they used describing specific events and actions but you didn't discuss whether they were describing the aircraft state accurately. Further, their choice of words is designed to not make a definitive statement on crew mindset unless they specifically have it documented. The listing of operable systems is functional and provides information to those unfamiliar with information on the state of the aircraft. Finally, they are judging. That is their stated role in the US by law.

[jmorrison]

I strongly recommend practitioners lose the terms “investigation” and “incriminator”. Those terms are not going to get much cooperation and information from those involved.