Effects of a systems approach in occurrence investigations (2024)

Summary

In 2017, a change (serendipity) in the philosophy of occurrence investigations took place at NS (Dutch Railways). It seems the investigations conducted and published before and after 2017 are different, both in the way the investigations are executed and in their effects on the organisation. This research has been carried out to find out if, in what way, and to what degree the two specific types of investigations are different with a special interest in the effects of the investigations on the organisation.

This research, published by Lund Universities Libraries, comprises two parts. In part 1 a comparative analysis is conducted on investigation reports — scrutinising five reports pre-2017 and four reports post-2017. The analytical framework is derived from Hollnagel's categorisation regarding incident investigation models, which delineates three models: sequential, epidemiological, and systemic.

The findings show that there are distinctions in both the nature and effects of the investigation reports. Investigations conducted pre-2017 exhibit characteristics of the sequential model due to a focus on what went wrong, (broken) components and measures that mostly aim at the sharp end operator (train drivers, conductors, train dispatcher) such as training and discussing specific findings of the investigations with those involved only.