Abstract
Engineering accident investigations are systematic inquiries into the facts and causes of engineering accidents. The aims of an engineering accident investigation include identifying significant truths about an accident, learning lessons to prevent similar future accidents, and authoritatively communicating the investigative results to the stakeholders. An important normative dimension along which an engineering accident investigation can be evaluated is its degree of success in fulfilling these aims. In this paper, I propose criteria for evaluating the degree of success of an engineering accident investigation using a question-centered framework, and then argue for the relevance of this proposal to the actual engineering practice. The basic idea of my proposal is that an engineering accident investigation is successful to the extent that (1) questions that should arise in the investigation do arise, and (2) questions that arise—especially the more significant ones—are resolved satisfactorily by the end of the investigation. The first part of this paper unpacks my proposal by analyzing the following three concepts and illustrating them using examples from the TWA Flight 800 accident investigation: The (satisfactory) resolution of questions, the significance of questions, and the arising of questions. The second part of this paper argues for the relevance of my proposal to the practitioners and stakeholders of engineering accident investigations. First, I argue that my proposal is sensitive to the aims of the investigators and stakeholders regarding engineering accident investigations, and that it helps them navigate competing and conflicting aims. Second, I go beyond the TWA 800 case study and argue that my proposal explains the strengths and limitations of different types of accident causation models used in investigations.
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Notes
This definition covers a broad range of engineering accidents: It covers accidents in various domains, including transportation accidents, industrial plant accidents, and software accidents. It covers major engineering disasters and minor consumer product accidents. It covers engineering accidents that are primarily technical in nature, and engineering accidents with organizational and social causes. Even though the primary case study in this paper is a transportation accident, my proposal is intended to apply to investigations into all types of engineering accidents.
Communicating the results to the stakeholders is an essential part of accident investigations (Heuvel, 2005, p. 113). Communications can take various forms, including official accident reports, academic publications, public hearings, and safety briefing sessions.
My approach in this paper has affinities with the framework for evaluating the quality of failure explanations developed by Barman and van Eck (2021); Barman (2022). My proposal was developed independently and focused on a different research question, however, and I will make no attempt to draw comparisons to their work.
An overpressure event creates sufficient pressure in a short time to cause damage in a structure.
I follow Elliott and Willmes (2013) by defining a cognitive attitude as an evaluative response directed toward some content, such as a proposition, a hypothesis, a model, a theory, or a question.
The distinction between epistemic and non-epistemic values has played an important role in recent debates about the role of values in science (See, e.g., Elliott and Steel, 2017, Part I-II). Precisely how the distinction should be drawn is controversial, although standard examples of non-epistemic values include personal, ethical, social, political, economic, cultural, and aesthetic values.
I follow Tuomela (2000) by calling this concept of acceptance “pragmatic acceptance”.
In engineering accident investigations, the negative consequences of fully and officially accepting false conclusions may include: (1) Using false conclusions as premises and guiding further investigations down the wrong path, thereby wasting time and resources. (2) Making ineffective recommendations based on false conclusions. (3) Authoritatively announcing false conclusions to the stakeholders and risking the reputation of the investigators. Failure to accept true conclusions also has negative consequences.
This point corresponds to characteristic (1).
These points correspond to characteristics (2), (3), and (4).
These points correspond to characteristics (5), (6), and (8).
This point corresponds to characteristic (7).
A related argument for this claim relies on the fact that engineering accident investigations have practical goals in addition to epistemic ones. Since the resolution of questions in these investigations serves non-epistemic goals, decisions about question resolution should consider the extent to which relevant non-epistemic goals are achieved. This argument is inspired by the “the aims approach” to explicating the role of non-epistemic values in science; see Elliott (2013) and Elliott and McKaughan (2014).
See James Kallstrom, “Fireball (TWA Flight 800)”, https://fbistudies.com/wp-content/uploads/2016/10/FBI-Grapevine-TWA-Flight-800.pdf.
In this paper, I am not committed to a particular theory of evidence beyond the following idea: A piece of evidence is a good reason for an epistemic agent to accept a claim (Achinstein, 2010, p. 38), although it doesn’t have to be conclusive and could be defeated by further information.
How much evidence counts as being “sufficiently strong” depends on the evaluator’s standards, which could be influenced by the evaluator’s non-epistemic goals and value judgments.
Unfortunately, the NTSB’s answer to the question “What did the witnesses observe?” failed to convince many witnesses of the accident. This failure, together with the NTSB’s inability to resolve the question about the ignition source of the center wing fuel tank explosion, contributed to the perception among some stakeholders that the TWA Flight 800 accident investigation is less than successful (Miller, 2002).
The concept of critical significance is defined only for resolved questions.
In this section, the term “investigation” always refers to engineering accident investigations.
I assume that there is a unique investigator responsible for each engineering accident investigation, and this investigator could be an individual or a group. Larger-scale investigations such as aviation accident investigations are typically carried out by organized groups. In such cases, the expression “the investigator responsible for the investigation” refers to the investigative group.
By an “evaluator”, I mean anyone who evaluates the degree of success of an investigation. The evaluators may be the investigators themselves or other stakeholders of the investigation.
Thanks to an anonymous reviewer for pointing this out to me.
A fault is “an anomaly in the functional operation of an equipment or system” (Carlson, 2012, p. 322).
On the other hand, completing a CAST analysis for a complex accident is difficult and time-consuming, and the results of the analysis are likely not useful for assigning blame (Leveson, 2004, p. 267). If the aims of an accident investigation were to produce quick fixes or to assign blame, then using CAST would not be conducive to achieving these aims.
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Acknowledgements
I would like to thank Helen Longino, George Smith, David Hills, Thomas Icard, Ted Toadvine and two anonymous reviewers for very helpful comments on earlier drafts of this paper.
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Wang, Y. Criteria of success for engineering accident investigations: a question-centered account. Euro Jnl Phil Sci 14, 16 (2024). https://doi.org/10.1007/s13194-024-00578-5
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DOI: https://doi.org/10.1007/s13194-024-00578-5