The NRI foundation maintains the manual on Events and Conditional Factors Analysis. Investigators use it to create rigorous descriptions of accidents. When we wrote the ECFA+ manual, we came up with a set of rules that limit the analysis to the what and the how of an accident. We deliberately excluded the why. It’s not that the why is unimportant, it’s just that mixing the jobs of describing and explaining can mean that neither is done well. As, Ludwig Benner—a prince amongst investigators—noticed: the resulting analysis tends to be sloppy. We thought that to create a solid basis for explanations, the description should be done first, and done well. However, handing analysts a bridle seemed a terrible cheek, so we felt obliged to explain our thinking at length in the manual. That is why, tucked away in the back, you will find a précis of Germund Hesslow’s paper on causal selection. If we can look at an accident from different points of view, he asks, which perspective is the right one? He points out, for example, that the ancient Greek word for cause, aitia, also meant guilt. In those times, the Greeks derived their ideas about physical causation from their model of social organisation.The ECFA+ rule set tries to prevent social explanations distorting physical descriptions. ‘What went wrong?’ seems such a natural question, but it is a loaded one. It can make the difference, for example, between learning not to get caught, and learning how to work safely.
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