The dynamics of disaster: A three‐dimensional view of documentation in a tightly regulated industry

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Abstract
Although effective public policy depends upon accurate post‐accident reports and investigations, accident reports in a large government agency reflect a linear, sequential model of cause and effect that fails to account for the multidimensional nature of accidents in tightly coupled technologies. As a result, unions, agencies, and operators engage in fiercely contested public debates over responsibility and authority when disasters occur. In proposing a three‐dimensional model of accident analysis (both visual and verbal), this article illustrates how underlying models of causality influence the structure of technical reports and the nature of the argument over responsibility and authority in largescale technological disasters.

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