Results of a preliminary survey into the usability of accident and incident reports

Accident reports tend to focus on direct causes like human error, without considering the defects that gave rise to the situation wherein the error occurred or the organisational arrangements wherein it occurred. Designers and regulators need this information in order to prevent future accidents. The problem we are trying to understand therefore has two features: Firstly we need to better understand the kind of information needed from accidents. As we have shown above there is a need to understand the context of action in order to better determine causation. Secondly, we need to understand the way in which information is currently transferred from events. The gap between these two aspects, what is needed and what is actually presented, can be seen as the context of our study.