Implementing recommendations from accident investigations: a case study of inter-organisational challenges.

In many industries, a national accident investigation board conducts investigations following major accidents. For safety improvements to be achieved, however, it is essential that the recommendations presented in these investigations are followed by necessary actions. In this paper, challenges related to implementation of recommendations from accident investigations are studied. The theoretical framework providing the foundation for the study lies at the intersection between systems safety, risk governance, and implementation research. Empirical data for the case study was collected from the Swedish railway sector. The first part of the paper presents an analysis of the extent of recommendations that have not resulted in implemented actions. The second part consists of an interview study aiming at providing a deeper understanding of the difficulties related to transforming these recommendations into actual changes. Two key factors that give rise to challenges to implementation of recommendations are identified. The first factor is related to the different actors' views on their own and other stakeholders' roles in the implementation process, and can be described as a trade-off between being insider and outsider to the industry. The second factor is related to the scope of the accident investigations and their recommendations, and can be described as a trade-off between micro-level and macro-level factors. The opportunities for implementing recommendations, and achieving safety improvements at the industry level, are affected by the ways in which the different stakeholders manage these trade-offs at the local level. This study thus mainly contributes by highlighting the importance of co-ordinating the various actors involved in the implementation process, and the results show that challenges to implementation to a large extent arise in the interactions between these actors.