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Missed opportunities in accident investigation

机译：事故调查中错过的机会

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There is an old story about two manufacturers of shoes who sent representatives to an undeveloped country to look into the opportunities for sales there. Both of them soon sent reports back. One said, 'No business here. People don't wear shoes'. The other said, 'Great opportunities here. People don't wear shoes'. Both representatives had the same data but their interpretations of it were different and told us more about them than about the opportunities for sales. Similarly, different accident investigators can draw different conclusions from the same evidence and propose different actions. The collection of evidence is usually adequate, at least in the oil and chemical industries, but the interpretations of the evidence vary and we often miss opportunities to learn from it. Some accident reports tell us more about the interests, experiences and beliefs of the investigators than about the best ways of preventing it happening again. In a paper presented at the Hazards XVI Conference in 2001 I described a number of learning opportunities that are frequently missed, during or following the preparation of a report. Having paid the 'tuition fee', we should learn the lessons. This paper summarises the 2001 paper, with a few changes, and illustrates some of the missed opportunities by different examples.
机译：有一个古老的故事说，有两家鞋履制造商派代表到一个不发达国家去调查那里的销售机会。他们俩都很快将报告发回。有人说：“这里没事。人们不穿鞋。另一个说：“这里的机会很大。人们不穿鞋。两位代表都有相同的数据，但是他们对数据的理解不同，因此，向我们介绍的不仅仅是销售机会。同样，不同的事故调查人员可以从相同的证据得出不同的结论，并提出不同的措施。至少在石油和化学工业中，证据的收集通常是足够的，但是证据的解释各不相同，我们经常会错失向其学习的机会。一些事故报告比起防止事故再次发生的最佳方法，更多地告诉我们调查人员的兴趣，经验和信念。在2001年召开的第16届Hazards XVI会议上，我描述了许多在准备报告期间或之后经常错过的学习机会。支付了“学费”后，我们应该学习课程。本文对2001年的论文进行了总结，并作了一些改动，并通过不同的例子说明了一些错失的机会。

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