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Human Factors in Incident Investigation

Spirit of Free Enterprise disaster case study used to highlight HF factors from the subsequent inquest.

Simply attributing incidents to human error is not adequate. In an incident investigation, to properly explain human behaviour we need to explore this in terms of people’s interactions with each other and with wider system / performance influencing factors. Investigations must look for multiple underlying causes rather than focusing on direct actions and immediate causes. Understanding the quality of Performance Influencing Factors (PIFs) which have been involved in the incident is vital. These can be a range of things throughout an organisation, see the examples below.

MESSAGE FROM STEP CHANGE IN SAFETY - HUMAN FACTORS WORKGROUP MEMBER: JASON PARK, HSEQ SUPERINTENDENT, KCA DEUTAG

"The point of any investigation is to learn and improve to prevent a recurrence. Investigations should be viewed as learning opportunities to understand why people and indeed organisations perform as they do with the information they have at that time and if that behaviour will be repeated unless improvements are made. Good practice:

  • Error traps
  • Organisational factors (why error traps were there)
  • Dependencies between individuals and teams
  • Implications of alternative choices
  • Rich description allowing the reader to appreciate the context and situation
  • Behaviour / decisions of multiple people explained including supervisors, engineers etc.
  • Corrective actions are mainly engineering / process focused."

Featured Resources

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Human Factors

Read our new Human Factors - Safety Moment Pack
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Human Factors

Download our Hydrocarbon Release Prevention Guidance
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Core topic 2: HF in accident investigations

Download external resource - Core topic 2: HF in accident investigations - HSE
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CIEHF-Learning-from-Adverse-Events

Download external resource - CIEHF-Learning-from-Adverse-Events - CIEHF
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Demystifying HF - building confidence in human factors investigation

Download external resource - Demystifying HF - building confidence in human factors investigation - IOGP

Human Factors in Incident Investigation - Regulatory Requirements

Regulator Guide - Offshore

  • Not applicable

Onshore COMAH

  • Developed, and is implementing, a clear, written standard that defines how HF will be integrated into accident/incident investigation processes.
  • Used accident, incident or near-miss investigations to identify immediate human failures and underlying causes (including relevant human and organisational factors).
  • Investigations allow an understanding of why human failures occurred in accidents/incidents and appropriate site-wide improvement actions to be implemented.

Annual Themes 2022: Q2 Human Factors and Human Performance