31
Human Factors in Accident Investigation
• The investigation should focus not only on immediate events at a local level
( site visits, interviews with operators, line managers and so on) but on a
range of wider issues:
• Visit other sites where the same or similar operations are conducted to
identify any generic risks and to determine whether any safety recommendations might apply more widely
• Determine whether similar incidents have happened before, how
where they investigated and what was found. How did the organisation
respond? Any reports into previous accidents should be reviewed
• Gain an understanding of the organisation’s safety management system,
whether HF plays a role and review the Hazard Log ( if available)
• Review any policies and procedures that govern the operations in the
accident.
• HF Integration: One way to understand how hazards and risks get into systems is by reviewing the processes the organisation uses to design systems
and to manage safety throughout the system life cycle. HF is now integrated
into procurement in some organisations via formal policy ( e.g. Ministry of
Defence 2015). Some features of successful integration include:
• A HF integration plan was developed at the early stages. Risks were
identified early and designed out of the system
• The requirements for safe operation were specified early on and tests
were undertaken to ensure that they were met before the system was
accepted into operation
• Tests involved real users and operators who were consulted early on
• Lessons from accidents in previous systems were identified and learned
• Early involvement of Human Factors professionals ( SQEP) is mandatory.
The concepts described in this chapter can be usefully applied to the investigation
of safety occurrences to provide answers to the questions above. These answers will
provide the evidence to support the drafting of safety recommendations, enabling
organisations to improve safety by learning from safety occurrences. As Kilskar
et al. ( 2019) have pointed out:
Sensemaking has often been limited to an organizational context, seldom discussing
issues such as system design … it is pointed out that safety science seems to have drifted
from the engineering and design side of system safety toward organizational and social
sciences or refinement of probabilistic models; thus, there is a need to focus more on
design and design principles to be able to diagnose hazardous states in operations
REFERENCES
Bridger, R.S. 2015. Human Factors in Accident Investigation and Safety Management.
Conference on Human Factors in Control: Accident Prevention: Learning and Changing
from Investigations. Britannia Hotel, Trondheim, Norway, 14–15 October 2015.
Bridger, R.S. 2018. Introduction to Human Factors and Ergonomics. Fourth ed. CRC Press,
Boca Raton, FL.
Bridger, R.S., Johnsen, S., Brasher, K. 2013. Psychometric properties of the cognitive failures
questionnaire. Ergonomics, 56:1515–1524.
Human Factors in Accident Investigation
• The investigation should focus not only on immediate events at a local level
( site visits, interviews with operators, line managers and so on) but on a
range of wider issues:
• Visit other sites where the same or similar operations are conducted to
identify any generic risks and to determine whether any safety recommendations might apply more widely
• Determine whether similar incidents have happened before, how
where they investigated and what was found. How did the organisation
respond? Any reports into previous accidents should be reviewed
• Gain an understanding of the organisation’s safety management system,
whether HF plays a role and review the Hazard Log ( if available)
• Review any policies and procedures that govern the operations in the
accident.
• HF Integration: One way to understand how hazards and risks get into systems is by reviewing the processes the organisation uses to design systems
and to manage safety throughout the system life cycle. HF is now integrated
into procurement in some organisations via formal policy ( e.g. Ministry of
Defence 2015). Some features of successful integration include:
• A HF integration plan was developed at the early stages. Risks were
identified early and designed out of the system
• The requirements for safe operation were specified early on and tests
were undertaken to ensure that they were met before the system was
accepted into operation
• Tests involved real users and operators who were consulted early on
• Lessons from accidents in previous systems were identified and learned
• Early involvement of Human Factors professionals ( SQEP) is mandatory.
The concepts described in this chapter can be usefully applied to the investigation
of safety occurrences to provide answers to the questions above. These answers will
provide the evidence to support the drafting of safety recommendations, enabling
organisations to improve safety by learning from safety occurrences. As Kilskar
et al. ( 2019) have pointed out:
Sensemaking has often been limited to an organizational context, seldom discussing
issues such as system design … it is pointed out that safety science seems to have drifted
from the engineering and design side of system safety toward organizational and social
sciences or refinement of probabilistic models; thus, there is a need to focus more on
design and design principles to be able to diagnose hazardous states in operations
REFERENCES
Bridger, R.S. 2015. Human Factors in Accident Investigation and Safety Management.
Conference on Human Factors in Control: Accident Prevention: Learning and Changing
from Investigations. Britannia Hotel, Trondheim, Norway, 14–15 October 2015.
Bridger, R.S. 2018. Introduction to Human Factors and Ergonomics. Fourth ed. CRC Press,
Boca Raton, FL.
Bridger, R.S., Johnsen, S., Brasher, K. 2013. Psychometric properties of the cognitive failures
questionnaire. Ergonomics, 56:1515–1524.