29
Human Factors in Accident Investigation
• Officers were told not to use the Loran-c ( RADAR) when at sea but to rely on the
ECDIS (GPS-based) system
• The two systems had been decoupled as a matter of policy, making the system
brittle and depriving the officers of important cues.
As is illustrated by the example in Figure 2.3, people are often insensitive to counterfactual evidence when everything seems OK, therefore the salience of the red light
may have been lost.
The above is a short summary of selected parts of the official report ( National
Transportation Board 1997). As was stated earlier, the purpose of HF investigations
is to make safety recommendations, and in this respect the report is fairly comprehensive, targeting recommendations at different levels to a number of different
authorities:
• To the US coastguard:
• To the Cruise Line
• To the National Marine Electronics Association
• To the developers of integrated bridge systems
• To the International Electrotechnical Commission
• To the manufacturers of ship positioning systems
• To the international council of cruise lines
• To the international chamber of shipping and the international association of independent tanker owners
This example illustrates how the inclusion of HF as an important theme in the
investigation increases our understanding of why the incident happened and generates a rich set of safety recommendations to avoid future incidents of this kind.
MAKING SENSE OF SAFETY OCCURRENCES – THE
CONTRIBUTION OF HUMAN FACTORS
As stated at the beginning of this chapter, the purpose of safety investigations is
to make safety recommendations. HF contributes to this process firstly by analysing the events that took place during a thin slice of time in the immediate vicinity
to identify errors or violations ( Figure 2.5) in relation to any PSFs ( Figure 2.2).
A deeper investigation then follows to understand the systemic factors that created the situation in the first place – a macro-ergonomic analysis of the system
(Figure 2.7).
SOME KEY CONSIDERATIONS FOR HUMAN
FACTORS IN ACCIDENT INVESTIGATIONS
The author has acted as a member of an investigation panel, as a Human Factors
Advisor to Service Inquiries in the Royal Navy and as an advisor to Safety
Investigation Teams in the UK National Health Service. Based on these experiences,
Human Factors in Accident Investigation
• Officers were told not to use the Loran-c ( RADAR) when at sea but to rely on the
ECDIS (GPS-based) system
• The two systems had been decoupled as a matter of policy, making the system
brittle and depriving the officers of important cues.
As is illustrated by the example in Figure 2.3, people are often insensitive to counterfactual evidence when everything seems OK, therefore the salience of the red light
may have been lost.
The above is a short summary of selected parts of the official report ( National
Transportation Board 1997). As was stated earlier, the purpose of HF investigations
is to make safety recommendations, and in this respect the report is fairly comprehensive, targeting recommendations at different levels to a number of different
authorities:
• To the US coastguard:
• To the Cruise Line
• To the National Marine Electronics Association
• To the developers of integrated bridge systems
• To the International Electrotechnical Commission
• To the manufacturers of ship positioning systems
• To the international council of cruise lines
• To the international chamber of shipping and the international association of independent tanker owners
This example illustrates how the inclusion of HF as an important theme in the
investigation increases our understanding of why the incident happened and generates a rich set of safety recommendations to avoid future incidents of this kind.
MAKING SENSE OF SAFETY OCCURRENCES – THE
CONTRIBUTION OF HUMAN FACTORS
As stated at the beginning of this chapter, the purpose of safety investigations is
to make safety recommendations. HF contributes to this process firstly by analysing the events that took place during a thin slice of time in the immediate vicinity
to identify errors or violations ( Figure 2.5) in relation to any PSFs ( Figure 2.2).
A deeper investigation then follows to understand the systemic factors that created the situation in the first place – a macro-ergonomic analysis of the system
(Figure 2.7).
SOME KEY CONSIDERATIONS FOR HUMAN
FACTORS IN ACCIDENT INVESTIGATIONS
The author has acted as a member of an investigation panel, as a Human Factors
Advisor to Service Inquiries in the Royal Navy and as an advisor to Safety
Investigation Teams in the UK National Health Service. Based on these experiences,