Trends and Characteristics in Health Care-related Deaths Investigated through Medico-legal Autopsies after System Changes in Japan.

In Japan, a new cause-of-death investigation system and related new laws were enacted in the mid-2010s. These laws provided for an autopsy system for non-criminal unnatural deaths and a medical accident investigation system outside the criminal justice process for health care-related deaths. We retrospectively explored changes in the number and characteristics of medico-legal autopsy cases of health care-related deaths in Chiba Prefecture, Japan, and examined trends over time during these reforms. We found that the percentage of forensic autopsies based on the Code of Criminal Procedure for health care-related deaths had decreased significantly. The number of autopsies of accidental and unintentional deaths in nursing homes, which are not covered by the newly established medical accident investigation system, has been increasing, reflecting the ageing of society. The trend toward decriminalisation of health care-related deaths was expected to contribute more to medical safety if the scope was expanded and a system for disclosure of autopsy information was established.

[Investigation and analysis of 7 cases of acute lung injury caused by a welding operation].

Objective: Throughing the investigation and analysis of seven cases of acute lung injury caused by a welding operation, the hazards and production pathways of harmful gases such as phosgene and nitrogen oxides are understood, which will serve as a reference for preventing similar events in the future. Methods: Throughing the accident scene environment investigation and clinical case analysis, combined with the laboratory test results, carried on the comprehensive analysis. Results: The accident caused a total of 7 people to suffer from acute lung injury to varying degrees. Three of them were sent to the ICU ward for treatment due to acute respiratory failure. After active treatment, 7 people were discharged from the hospital with obvious relief. Conclusion: Welding is also a kind of profession that causes the high incidence of acute lung injury accidents. It is necessary to strengthen the knowledge training and protection awareness education of welding workers to avoid the occurrence of acute harmful gas poisoning accidents.

Challenges in investigation of diabetes-related aviation fatalities-an analysis of 1491 subsequent aviation fatalities in USA during 2011-2016.

Diabetes mellitus (DM) could cause pilot incapacitation and result in aviation fatalities. The mechanisms could be directly as a consequence of acute hypoglycemia/subacute diabetic ketoacidosis (DKA) or indirectly as an acute cardiovascular event by contributing to the development of atherosclerosis in coronary or carotid and cerebral arteries. In this study, DM-related fatal flight accidents in the US National Transport Bureau's database between years 2011-2016 were analyzed with special emphasis on postmortem (PM) glucose levels and correlation of toxicological reports with anamnestic information on DM. Additionally, autopsy results on coronary arteries were reviewed. In 43 out of 1491 (~ 3%) fatal accidents pilots had DM. Postmortem glucose or glycated hemoglobin percentage (Hb1Ac) was measured in 12 of the 43 cases; while antidiabetic medication was found in 14 of the cases (only two of the cases had both glucose measurements and medication). With the increasing prevalence of DM, a possibility of pilot incapacitation due to DM or complications of DM should be actively studied, even if no anamnestic information of DM was available. While PM hypoglycemia is difficult to assess, we propose a systematic investigation based on measurement of glucose, Hb1Ac%, and ketone bodies, and documentation of atherosclerotic lesions in major arteries to identify or rule out DM as a cause of pilot incapacitation.

Serious injury and fatality investigations involving pneumatic nail guns, 1985-2012.

BACKGROUND: This article examines serious and fatal pneumatic nail gun (PNG) injury investigations for workplace, tool design, and human factors relevant to causation and resulting OS&H authorities' responses in terms of citations and penalties. METHODS: The U.S. Occupational Safety and Health Administration (OSHA) database of Fatality and Catastrophe Investigation Summaries (F&CIS) were reviewed (1985-2012) to identify n = 258 PNG accidents. RESULTS: 79.8% of investigations, and 100% of fatalities, occurred in the construction industry. Between 53-71% of injuries appear to have been preventable had a safer sequential trigger tool been used. Citations and monetary penalties were related to injury severity, body part injured, disabling of safety devices, and insufficient personal protective equipment (PPE). CONCLUSIONS: Differences may exist between construction and other industries in investigators interpretations of PNG injury causation and resulting citations/penalties. Violations of PPE standards were penalized most severely, yet the preventive effect of PPE would likely have been less than that of a safer sequential trigger.

Using simulation to improve root cause analysis of adverse surgical outcomes.

OBJECTIVE: The purpose of this study was to develop and test a simulation method of conducting investigation of the causality of adverse surgical outcomes. DESIGN: Six hundred and thirty-one closed claims of a major medical malpractice insurance company were reviewed. Each case had undergone conventional root cause analysis (RCA). Claims were categorized by comparing the predominant underlying cause documented in the case files. Three cases were selected for simulation. SETTING: All records (medical and legal) were analyzed. Simulation scenarios were developed by abstracting data from the records and then developing paper and electronic medical records, choosing appropriate STUDY PARTICIPANTS: including test subjects and confederates, scripting the simulation and choosing the appropriate simulated environment. INTERVENTION: In a simulation center, each case simulation was run 6-7 times and recorded, with participants debriefed at the conclusion. MAIN OUTCOME MEASURES: Sources of error identified during simulation were compared with those noted in the closed claims. Test subject decision-making was assessed qualitatively. RESULTS: Simulation of adverse outcomes (SAOs) identified more system errors and revealed the way complex decisions were made by test subjects. Compared with conventional RCA, SAO identified root causes less focused on errors by individuals and more on systems-based error. CONCLUSIONS: The use of simulation for investigation of adverse surgical outcomes is feasible and identifies causes that may be more amenable to effective systems changes than conventional RCA. The information that SAO provides may facilitate the implementation of corrective measures, decreasing the risk of recurrence and improving patient safety.

Investigation of annual trucks fatal accidents in El Hajeb province of Morocco using TRIZ-Ishikawa diagram.

A stretch of road in the province of EL HAJEB, located in the central-south region of Morocco, is classified among the roadways experiencing an accumulation of fatal traffic accidents, with a particular involvement of freight transport vehicles. Investigation reports elaborated for these fatal accidents specify that these accidents occurred when drivers lost control of their vehicles due to brake system failures, resulting in multiple fatalities. However, these investigation reports did not provide root causes of this phenomena. Scientific research efforts in this field are directed toward preventive solutions and proposing a comprehensive analytical approach. This study aims to elucidate the mechanisms behind these specific accident phenomena on the identified stretch in the city of EL HAJEB. To achieve the study's objective and identify the triggering or contributing factors of these failures, we employed a novel approach combining the TRIZ and Ishikawa tools. This is a systematic methodology for analyzing potential causes of accidents, allowing us to clarify the intricacies of the specific phenomena leading to accidents while systematizing the analysis process, thus contributing to enhancing the effectiveness of investigative teams. This article contributes to introducing a new analytical tool in the field of accident analysis.

Evaluation and comparison of selected methodologies to investigate occupational accidents.

BACKGROUND: The choice of the "right" methodology to carry out the occupational accident investigation process is not an easy task. Each methodology has different conceptual and practical characteristics. The choice will depend to a large extent on the conceptual accident model being used. OBJECTIVE: The aim of this study has been to evaluate and compare a set of nine methodologies recognised as the most widely used in the field of occupational accident investigation. METHODS: For this purpose, six evaluation criteria are used which have already been applied and validated by the scientific community with a clear emphasis on the holistic nature of these methodologies. RESULTS: The results show a detailed analysis of the conceptual, methodological and practical characteristics of the nine selected occupational accident investigation methodologies. The conceptual framework of each of the methodologies, their holistic characteristics in terms of whether they cover the complete information cycle and its possible interrelation, reliability and validity of the methodologies, the experience required for their application, the flexibility in terms of being able to be used in different work environments and finally the ability of the methodology to motivate organisational improvement are presented. CONCLUSIONS: From this study, it is clear that the analysis of occupational accident investigation it is becoming increasingly necessary to employ scientific methodologies with a clear proactive approach in order to meet the challenges of changing socio-technical systems.

Systematically investigating human and organisational factors in complex socio-technical systems by using the "SAfety FRactal ANalysis" method.

In order to manage the performance of socio-technical systems in a safe and sustainable way, the importance of looking at human and organisational factors (HOF) and their contribution to adverse events is widely recognised. In reality, however, the scope of accident and incident investigations stays usually limited to investigating the immediate causes and decision-making processes related to the accident sequence (e.g. Antonsen, 2009). Important factors, including design and planning decisions, contributing to accidents are hereby often overlooked and the weaknesses in the Safety Management System are hardly ever analysed. The SAfety FRactal ANalysis (SAFRAN) method (Accou and Reniers, 2019) can guide investigators in an intuitive and logic way, to ask questions that help to gain deeper understanding of the capability of organisations to monitor and manage safety critical variability. The essence of using the SAFRAN method for evaluating the performance of the different processes in a socio-technical system, is to approach them in a similar way, building on the generic elements that compose a SMS and systematically looking at the HOF that influenced actions and decision making, regardless of the hierarchical level they are situated at. This paper presents the SAFRAN method, specifying its HOF taxonomy and sharing examples of supporting HOF questions. The approach enables non-experts in HOF to systematically identify the different elements that introduce critical variability in performance and to recognise what additional expertise can be called upon when needed.

Applying principles of fatigue science to accident investigation: Transportation Safety Board of Canada (TSB) fatigue investigation methodology.

Fatigue that is related to the amount and quality of sleep obtained can impair human performance in ways that can lead to accidents. As many transportation industries operate around the clock, fatigue and its effects cannot be eliminated completely; instead, they must be managed. A first step is to document the prevalence and role of fatigue in accidents that occur. The Transportation Safety Board of Canada (TSB) routinely investigates such transportation industry incidents to determine if fatigue was present, if it played a role, and if there were practices in place to effectively manage it and associated risks. Herein, we summarize and describe the TSB's fatigue investigation methodology in the hopes that investigators of other organizations and domains will find the concepts applicable to their operational context.

Marine accident learning with fuzzy cognitive maps (MALFCMs).

Statistical analysis of past accidents in maritime may demonstrate the trends for certain contributing factors in accidents, however, there is a lack of a suitable technique to model the complex interrelations between these factors. Due to aforementioned complex interrelations and insufficient information stored in accident databases, it was not possible to understand the importance of each factor in accidents, which prevented researchers from considering these factors in risk assessments. Therefore, there is a need for a capable technique to estimate the importance of each factor. The results of such a technique can be used to inform risk assessments and predict the effectiveness of risk control options. Thus, this study introduces a new technique for Marine Accident Learning with Fuzzy Cognitive Maps (MALFCMs). The novelty of MALFCM is the application of fuzzy cognitive maps (FCMs) to model the relationships of maritime accident contributors by directly learning from an accident database as well as having the ability to combine expert opinion. As each fuzzy cognitive map is derived from real occurrences supported by expert opinion, the results can be considered more objective. Thus, MALFCM may overcome the main disadvantage of fuzzy cognitive maps by eliminating or controlling the subjectivity in results.•A novel MALFCM method to weight human-contributing factors into maritime accidents has been developed.•With MALFCM method the main disadvantage of traditional FCMs is overcome.•The MALFCM method can produce logical results even by solely using information from historical data in the absence of expert judgement.

Analysis of fatal factors influencing accidents involving two-wheel electric vehicle drivers at intersections.

With the development of society, the convenience offered by two-wheel electric vehicles has made them an ideal road-transportation option for daily short-distance travel. However, this also poses various road-safety concerns. This study aims to analyse the main factors causing fatal injuries at intersections for two-wheel electric vehicle drivers. This study uses 902 sets of data on two-wheel electric vehicle accidents that occurred in Shandong Province between 2014 and 2018 (obtained from the Shandong Tianhong Judicial Expertise Center database) to comprehensively analyse the nine factors that result in driver fatalities at road intersections. A dimensionality reduction of the factors via principal component analysis returned four main factors, namely the collision object, collision-object speed, running direction, and sight obstacles. A subsequent analysis of the main factors revealed that the most common collision object for two-wheel electric vehicle drivers is the automobile, with the most common speed during the collision being 50-60 km/h. Sight obstacles primarily include other vehicles as well as glaring lights. Two-wheel electric vehicles are most prone to accidents when turning left. This study comprehensively analyses the main factors that cause fatal injuries to two-wheel electric vehicle drivers at road intersections. Further investigations can be conducted to analyse the impact of the specific conditions of the two-wheel electric vehicle collisions on the mortality of drivers.

Application of an Improved Model for Accident Analysis: A Case Study.

An improved accident causation model which demonstrates the relationships among different causal factors was proposed in this study. It provides a pathway for accident analysis from the individual level to the organizational level. Unsafe acts and conditions determined by individuals' poor safety knowledge, low safety awareness, bad safety habits, etc. are the immediate causes of an accident. Deficiencies in safety management systems and safety culture remain the root causes, which can cause consequences at the individual level. Moreover, the weaknesses of an organization's safety culture can have a great impact on the formation of a good safety climate and can further lead to poor decision-making and implementation of procedures in the safety management system. In order to contribute to a better perception and understanding of the accident causation model, one typical case in the process industry, the oil leak and explosion of the Sinopec Donghuang pipelines, was selected for this study. The causality from immediate causes to root causes is demonstrated in sequence and can be shown in this model explicitly and logically. Several important lessons are summarized from the results and targeted measures can be taken to avoid similar mistakes in the future. This model provides a clear and resourceful method for the safety and risk practitioner's toolkit in accident investigation and analysis, and the organization can use it as a tool to conduct staff trainings and thus to keep accidents under control.

Effects of High-g Impact on Physical, Electrical, and Optical Characteristics of Light-Emitting Diodes.

Previously, one of the tools available in automotive or aircraft accident analysis was the examination of the indicator bulbs. Currently, indicator bulbs have been largely replaced by light-emitting diodes (LEDs). Here a series of studies was carried out on impact effects on LEDs to determine whether their properties change after impact, and whether it is related to its working status (lit or unlit). The LEDs were measured before mechanical shock with a series of tests, including current-voltage, current-light, bandwidth, subject to impact ranging from 450 g to 2000 g, and then retested. The tests showed consistent slight but statistically significant increases in forward voltages at a given current after impact, which could be used to estimate the impact. Some LEDS were imaged before and after impact with thermal and X-ray imaging, but no mechanical changes were seen. It was not possible to determine the LED's working status from these test results.

Determining the likelihood that fatigue was present in a road accident: A theoretical review and suggested accident taxonomy.

Estimates in developed countries of the extent to which fatigue contributes to road accidents range from as low as 5% to as high as 50% of all accidents. Compared with other causes of road accidents (e.g., speeding, drink-driving), the variability in these estimates is exceptionally high and may be indicative of the difficulty in determining the likelihood of fatigue as a cause of road accidents. This review compares differences in the way road accidents are classified as fatigue-related (or not) by expert panels and road safety regulators, highlighting conflicting conceptual approaches, lack of consistency, and the poor psychometric qualities of classification rules used across jurisdictions. In order to facilitate future research, the review then proposes a new theoretical approach and a potentially more logical accident 'taxonomy'. A putative accident 'taxonomy' is proposed using two dimensions: (1) estimating the likelihood that a driver was fatigued at the time of the accident, and (2) estimating the degree to which accident phenomenology is consistent with fatigue-related error. This 'taxonomy' could assist accident investigators and road safety regulators to more reliably quantify the contribution of fatigue to road accidents, and may also assist researchers and regulators in the post-hoc interrogation of existing accident databases to better determine the relative incidence of fatigue-related road accidents.

A modified accident analysis and investigation model for the general aviation industry: Emphasizing on human and organizational factors.

INTRODUCTION: Currently, there is a lack of specific analytical tools for general aviation accidents (GAAs). This has led to loopholes in the prevention of GAAs. METHODS: A Swiss Cheese model for general aviation (SCM-GA) is proposed to identify the human and organizational factors involved in GAAs. In the proposed SCM-GA, 5 categories, 45 subcategories, a general aviation safety management system (GA-SMS) and safety culture were developed based on the classic accident causation models combined with the laws and regulations and safety management practices in the general aviation industry. RESULTS: One GAA was analyzed using SCM-GA. The human and organizational causes revealed by SCM-GA were more complete than the causes revealed through the accident report. The identification results of the deficiencies in the subcategories of GA-SMS and the safety culture were more consistent with the requirements in the general aviation laws and regulations than the organizational factors in the accident report. Based on the subcategories of SCM-GA, 41 GAAs that occurred between 1996 and 2010 in China were statistically analyzed and χ2 test analyses were performed to estimate the statistical strength of the association between two adjacent subcategories of SCM-GA. The results showed that two adjacent subcategories of SCM-GA were significantly associated. They helped to determine the hidden problems in the accident report based on the path of accident. CONCLUSIONS: SCM-GA is an accident analysis tool that can comprehensively analyze the human and organizational deficiencies involved in GAAs. The accident causes revealed by SCM-GA were more consistent with the general aviation safety management practices. PRACTICAL APPLICATIONS: General aviation companies should establish their own GA-SMS and safety culture based on the subcategories developed herein. Using SCM-GA for routine safety inspection and accident investigation will help the management and the staff make effective safety decisions to effectively prevent GAAs.

Arabian, Asian, western: a cross-cultural comparison of aircraft accidents from human factor perspectives.

INTRODUCTION: Rates of aviation accident differ in different regions; and national culture has been implicated as a factor. This invites a discussion about the role of national culture in aviation accidents. This study makes a cross-cultural comparison between Oman, Taiwan and the USA. METHOD: A cross-cultural comparison was acquired using data from three studies, including this study, by applying the Human Factors Analysis and Classification System (HFACS) framework. The Taiwan study presented 523 mishaps with 1762 occurrences of human error obtained from the Republic of China Air Force. The study from the USA carried out for commercial aviation had 119 accidents with 245 instances of human error. This study carried out in Oman had a total of 40 aircraft accidents with 129 incidences. RESULTS: Variations were found between Oman, Taiwan and the USA at the levels of organisational influence and unsafe supervision. Seven HFACS categories showed significant differences between the three countries (p < 0.05). CONCLUSION: Although not given much consideration, national culture can have an impact on aviation safety. This study revealed that national culture plays a role in aircraft accidents related to human factors that cannot be disregarded.

Application of forensic image analysis in accident investigations.

Forensic investigations are primarily meant to obtain objective answers that can be used for criminal prosecution. Accident analyses are usually performed to learn from incidents and to prevent similar events from occurring in the future. Although the primary goal may be different, the steps in which information is gathered, interpreted and weighed are similar in both types of investigations, implying that forensic techniques can be of use in accident investigations as well. The use in accident investigations usually means that more information can be obtained from the available information than when used in criminal investigations, since the latter require a higher evidence level. In this paper, we demonstrate the applicability of forensic techniques for accident investigations by presenting a number of cases from one specific field of expertise: image analysis. With the rapid spread of digital devices and new media, a wealth of image material and other digital information has become available for accident investigators. We show that much information can be distilled from footage by using forensic image analysis techniques. These applications show that image analysis provides information that is crucial for obtaining the sequence of events and the two- and three-dimensional geometry of an accident. Since accident investigation focuses primarily on learning from accidents and prevention of future accidents, and less on the blame that is crucial for criminal investigations, the field of application of these forensic tools may be broader than would be the case in purely legal sense. This is an important notion for future accident investigations.

Construction accidents: identification of the main associations between causes, mechanisms and stages of the construction process.

OBJECTIVE: To identify the most frequent causes of accidents in the construction sector in order to help safety practitioners in the task of prioritizing preventive actions depending on the stage of construction. METHODS: Official accident investigation reports are analysed. A causation pattern is identified with the proportion of causes in each of the different possible groups of causes. RESULTS: Significant associations of the types of causes with accident mechanisms and construction stages have been identified. CONCLUSIONS: Significant differences have been found in accident causation depending on the mechanism of the accident and the construction stage ongoing. These results should be used to prioritize preventive actions to combat the most likely causes for each accident mechanism and construction stage.

Integration of Laser Scanning and Three-dimensional Models in the Legal Process Following an Industrial Accident.

BACKGROUND: In order to obtain a deeper understanding of an incident, it needs to be investigated to "peel back the layers" and examine both immediate and underlying failures that contributed to the event itself. One of the key elements of an effective accident investigation is recording the scene for future reference. In recent years, however, there have been major advances in survey technology, which have provided the ability to capture scenes in three dimension to an unprecedented level of detail, using laser scanners. METHODS: A case study involving a fatal incident was surveyed using three-dimensional laser scanning, and subsequently recreated through virtual and physical models. The created models were then utilized in both accident investigation and legal process, to explore the technologies used in this setting. RESULTS: Benefits include explanation of the event and environment, incident reconstruction, preservation of evidence, reducing the need for site visits, and testing of theories. Drawbacks include limited technology within courtrooms, confusion caused by models, cost, and personal interpretation and acceptance in the data. CONCLUSION: Laser scanning surveys can be of considerable use in jury trials, for example, in case the location supports the use of a high-definition survey, or an object has to be altered after the accident and it has a specific influence on the case and needs to be recorded. However, consideration has to be made in its application and to ensure a fair trial, with emphasis being placed on the facts of the case and personal interpretation controlled.

A systemic analysis of South Korea Sewol ferry accident - Striking a balance between learning and accountability.

The South Korea Sewol ferry accident in April 2014 claimed the lives of over 300 passengers and led to criminal charges of 399 personnel concerned including imprisonment of 154 of them as of Oct 2014. Blame and punishment culture can be prevalent in a more hierarchical society like South Korea as shown in the aftermath of this disaster. This study aims to analyse the South Korea ferry accident using Rasmussen's risk management framework and the associated AcciMap technique and to propose recommendations drawn from an AcciMap-based focus group with systems safety experts. The data for the accident analysis were collected mainly from an interim investigation report by the Board of Audit and Inspection of Korea and major South Korean and foreign newspapers. The analysis showed that the accident was attributed to many contributing factors arising from front-line operators, management, regulators and government. It also showed how the multiple factors including economic, social and political pressures and individual workload contributed to the accident and how they affected each other. This AcciMap was presented to 27 safety researchers and experts at 'the legacy of Jens Rasmussen' symposium adjunct to ODAM2014. Their recommendations were captured through a focus group. The four main recommendations include forgive (no blame and punishment on individuals), analyse (socio-technical system-based), learn (from why things do not go wrong) and change (bottom-up safety culture and safety system management). The findings offer important insights into how this type of accident should be understood, analysed and the subsequent response.