This study draws attention to the importance of the fact that accident analyses, their conclusions and recommendations for improvements differ depending on the purpose of the analysis and the analyst's basic professional training. An accident in a hospital in which three patients died during dialysis was used as an illustrative example. The result of the legal analysis is presented first. Using this perspective, the cause of the accident was judged to be errors made by the chief nurse who was the only one who was found guilty of the deaths of three people. She was given a conditional prison sentence. The action taken at the hospital was to remove her from her job. Later, engineering and psychology experts were asked about how they attributed responsibility for the accident. Finally, the Accident Evolution and Barrier Function (AEB) method was also used to analyse the accident. This method models an accident as an interaction between technical and human factors systems. The results illustrated how the conclusions concerning action to avoid an accident in the future differed widely following a legal analysis and an AEB analysis of the same accident. The data also showed that the responsibility for the accident was attributed to one single person in the legal analysis but chiefly to other agents by engineers and psychologists. Analysts with a basic training in engineering tended to find relatively more human factors errors than technical errors in the AEB analyses. The number of acceptable solutions created to avoid future errors were related to the analyst's basic professional training and/or motivation, but the basic AEB modelling of the accident evolution was relatively less dependent on the basic professional training of the analysts and/or motivation. It was argued that a legal framework can he inefficient or even contra productive in promoting improvements to the safety of complex integrated systems. This is particularly true if the convicted people are low in the hierarchy of an organization and cannot affect its future routines. It is also argued here that experts with different basic professional training should perform accident analyses jointly. This is because only then will there be an insightful coverage of the interactions between different systems as, for example, human factors and technological systems making it possible to increase the safety of a complex integrated system. (A)
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