17
Human Factors in Accident Investigation
errors but to identify and eliminate e rror-provoking factors in the work environment
that may have adverse effects.
PERFORMANCE SHAPING FACTORS ( PSFs)
IMPACTING HUMAN BEHAVIOUR
As we have seen, the approach of HF is to consider human behaviour in the context
of the system in which people are working. Performance shaping factors ( PSFs) are
aspects of the work environment and of human behaviour which influence system
performance. The context is nothing more than the sum of PSFs in workplace at the
time a safety occurrence took place ( F igure 2.2). PSFs are not causes, but they are
always relevant. Good ‘ detective work’ may be needed to identify the PSFs so that
we can learn from them and improve the work environment ( see, for example, Gould
et al. 2006). When investigating safety occurrences, the immediate focus is on the
events during a thin slice of time at the critical moment to understand the PSFs in
the immediate environment and to search for latent h azards – this might be called a
micro-ergonomic analysis. Next, the focus is on the organisation and the events leading up to the accident, seeking to discover why and how the PSFs were present in the
ENVIRONMENT
Extremes of heat/cold
Excessive noise
Confined space
High sea state
Poor lighting
Toxic hazards
Flammable materials
Weather conditions
Other
Consider whether the following Performance Shaping
Factors were present
ORGANISATION
Fatigue
Watch systems
High time on task
Poor team work
Communication problems
Inadequate maintenance
Poor record keeping
Conflicting goals
Poor instructions
Time pressure
Lack of supervision
Lack of training
No SOPs in place
Other
DESIGN
Workstation layout
Too many controls
Poor displays
Console design
Presence/absence of
warning signs
Screen layout
System response time
Adequacy of feedback
Poor sightlines
Visibility
Number of Warnings /
Alarms
Other
SAFETY OCCURRENCE
FIGURE 2.2 Performance shaping factors in safety management and accident investigation.
( From Bridger et al., 2012, Crown Copyright, Contains public sector information licensed
under the Open Government Licence v2.0.)
Human Factors in Accident Investigation
errors but to identify and eliminate e rror-provoking factors in the work environment
that may have adverse effects.
PERFORMANCE SHAPING FACTORS ( PSFs)
IMPACTING HUMAN BEHAVIOUR
As we have seen, the approach of HF is to consider human behaviour in the context
of the system in which people are working. Performance shaping factors ( PSFs) are
aspects of the work environment and of human behaviour which influence system
performance. The context is nothing more than the sum of PSFs in workplace at the
time a safety occurrence took place ( F igure 2.2). PSFs are not causes, but they are
always relevant. Good ‘ detective work’ may be needed to identify the PSFs so that
we can learn from them and improve the work environment ( see, for example, Gould
et al. 2006). When investigating safety occurrences, the immediate focus is on the
events during a thin slice of time at the critical moment to understand the PSFs in
the immediate environment and to search for latent h azards – this might be called a
micro-ergonomic analysis. Next, the focus is on the organisation and the events leading up to the accident, seeking to discover why and how the PSFs were present in the
ENVIRONMENT
Extremes of heat/cold
Excessive noise
Confined space
High sea state
Poor lighting
Toxic hazards
Flammable materials
Weather conditions
Other
Consider whether the following Performance Shaping
Factors were present
ORGANISATION
Fatigue
Watch systems
High time on task
Poor team work
Communication problems
Inadequate maintenance
Poor record keeping
Conflicting goals
Poor instructions
Time pressure
Lack of supervision
Lack of training
No SOPs in place
Other
DESIGN
Workstation layout
Too many controls
Poor displays
Console design
Presence/absence of
warning signs
Screen layout
System response time
Adequacy of feedback
Poor sightlines
Visibility
Number of Warnings /
Alarms
Other
SAFETY OCCURRENCE
FIGURE 2.2 Performance shaping factors in safety management and accident investigation.
( From Bridger et al., 2012, Crown Copyright, Contains public sector information licensed
under the Open Government Licence v2.0.)