In accident investigation, the ideal is often to follow the principle "what-you-find-is-what-you-fix", an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. Our purpose in this study was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of "what-you-find-is-what-you-fix". We conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. We found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organizational accidents, rather than reflecting flawed thinking. One particular limitation of investigation was that many investigations stop the analysis at the level of "preventable causes", the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get a view on the "big picture" of causes of accidents as a basis for further remedial actions.

Accident investigation manuals are influential documents on various levels in a safety management system, and it is therefore important to appraise them in the light of what we currently know - or assume - about the nature of accidents. Investigation manuals necessarily embody or represent an accident model, i.e., a set of assumptions about how accidents happen and what the important factors are. In this paper we examine three aspects of accident investigation as described in a number of investigation manuals. Firstly, we focus on accident models and in particular the assumptions about how different factors interact to cause - or prevent - accidents, i.e., the accident "mechanisms". Secondly, we focus on the scope in the sense of the factors (or factor domains) that are considered in the models - for instance (hu)man, technology, and organization (MTO). Thirdly, we focus on the system of investigation or the activities that together constitute an accident investigation project/process. We found that the manuals all used complex linear models. The factors considered were in general (hu)man, technology, organization, and information. The causes found during an investigation reflect the assumptions of the accident model, following the What-You-Look-For-Is-What-You-Find or WYLFIWYF principle. The identified causes typically became specific problems to be fixed during an implementation of solutions. This follows what can be called What-You-Find-Is-What-You-Fix or WYFIWYF principle.

Health care has evolved rapidly to meet the medical demands of society, but not to meet the demands of consistent operational safety. In other high risk domains in which the consequences of systems failure are unacceptable, organisational and operational work systems have been developed to deliver consistent, high-quality, failure-free performance. In this paper we review contributions to a special issue of Cognition, Technology and Work on 'Enhancing Surgical Systems'. We consider their implications for improving the reliability of care processes in light of theoretical developments in the area of high-reliability organisations and resilience engineering. Health care must move from reactive safety cultures to be more proactively resilient to the continual threats posed by complexity in clinical care processes and the multi-professional hospital environment. Our analysis emphasises the importance of team working for reliable operational performance. A schematic framework to illustrate how safety interventions in surgery might cohere within an organisational strategy for achieving high-reliability is proposed. The implications for continuous quality improvement and effective regulation of system safety over differing time scales and organisational levels are discussed. © 2007 Springer-Verlag London Limited.