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2
A Guide to Human
Factors in Accident
Investigation
R. S. Bridger
Knowledge Sharing Events Ltd. Past President Chartered
Institute of Ergonomics and Human Factors
INTRODUCTION
This chapter summarises a presentation made by the author at a safety conference in
Norway ( Bridger 2015). ‘ Learning and changing from investigations’ was the theme
of the conference, and the presentation aimed to illustrate how human factors ( HF)
can contribute to organisational learning and, in particular, the necessity of taking a
systems approach to generate safety recommendations.
It is widely recognised that HF competencies must be present in all incident
investigations and incident reports. Investigators and operators must be trained in
HF and/ or supported by qualified HF professionals. The author is currently working with the Royal Navy on the development of a learning pathway, taking a tiered
approach to train 4% of over 30,000 personnel as HF facilitators, 2% as HF supervisors, with smaller numbers of more highly trained personnel as HF trainer assessors
CONTENTS
Introduction
13
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Taking a Systems Approach
14
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Human Factors and ‘ Sense-Making’ in Accident Investigation
15
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Mitigating Sources of Risk in Systems through Human Factors in Design
16
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Performance Shaping Factors ( PSFs) Impacting Human Behaviour
17
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What Is Safety – A Human Factors Perspective
18
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Accidents as Failures of Safety Constraints
20
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Accidents and Human Error as a Starting Point in Analysis
21
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Situation Awareness
23
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Violations and Adaptations to Understand Work as Done
25
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Time Pressure – An Important Issue for Human Factors
26
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Are Some People ‘ Accident Prone? Characteristics, Causes and Mitigation
27
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Making Sense of Safety Occurrences – The Contribution of Human Factors
29
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Some Key Considerations for Human Factors in Accident Investigations
29
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References
31
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