Lessons Learned and Two Faces of Accident Case Study

Abstract

This chapter examines how fatal incident cases can be studied to inform future prevention, mindful of the distress which each tragedy has occasioned. It distinguishes between eliciting lessons and determining blame, considers how questions of blame can be negotiated, and the extent to which blame might be an unavoidable element in fatality cases. Outdoor education fatal accidents are circumstantial, and must be understood in context, but prevention must be imagined in contemporary circumstances. Changes in technology can afford opportunities for prevention not available at the time of a tragedy. Case-based prevention must work with material which is incomplete, or contestable; I argue that prevention requires a pragmatic search for whatever insights could be useful to those best placed to act. Prevention-focussed causal analysis is counterfactual, identifying “but for” causes of which there could be many. Fatality prevention requires action by individuals and case-analysis requires an understanding of how knowledge informs, or is embedded in, decision-making. In particularly, the chapter discusses the different roles of procedural knowledge and expert intuition. Case-based knowledge can be used to assess whether safety measures originating in industrial production are suited to outdoor education situations. The possibility that decisions about approaches to safety could be distorted by production pressure or cost considerations requires insight into the nature of expert knowledge and an understanding of the circumstances in which outdoor education decisions are made. Case-based knowledge is important because outdoor education expertise derived from experience would rarely involve significant first hand experience of fatal incidents.