Using PVS to investigate incidents through the lens of distributed cognition

Abstract

A systematic tool-based method is outlined that raises questions about the circumstances surrounding an incident: why it happened and what went wrong. The approach offers a practical and systematic way to apply a distributed cognition perspective to incident investigations, focusing on how available information resources (or the lack of them) may shape user action, rather than just on causal chains. This perspective supports a deeper understanding of the more systemic causes of incidents. The analysis is based on a higher order-logic model describing how information resources may have influenced the actions of those involved in the incident. The PVS theorem proving system is used to identify situations where available resources may afford unsafe user actions. The method is illustrated using a healthcare case study. © 2012 Springer-Verlag.