Why address human factors in investigations?
Incidents and near-misses are opportunities to learn and get better.
My experience as a safety inspector, a role that often involved reviewing company incident reports, was that many investigations simply concluded that the cause (or one of the causes) was ‘human error’; a phrase that has been over-used. The late Professor Trevor Kletz famously said that attributing incidents to human error was about as useful as saying that falls are due to gravity.
How to address human factors in investigations
If we are to learn as much as possible from investigations, then human factors must be addressed with some structure and rigour. There are tools and approaches that will assist, but ultimately, the investigation team must have some competence in human factors.
Reviewing the findings from major investigations, such as those described on the Incidents pages, will provide a good grounding into the issues to be considered. However, a good human factors investigation largely depends upon the mindset of the investigators.
In a series of five short videos summarising the key concepts from one of his books, Sidney Dekker outlines the pitfalls of the phrase ‘human error’, and explains some good practice for considering human factors in investigations. I’d highly recommend watching these videos, perhaps using them to introduce human factors to your investigators – this will be an hour well-spent.
Human factors training for investigators
In order to improve the quality of how human factors is addressed in investigations, I’d recommend that training for investigators should include the following:
- The types of human failures
- An understanding of the capabilities and limitations of human beings
- The factors that influence human failures (Performance Influencing Factors)
- A basic understanding of the key human factors topics
- An understanding of the ‘human error’ concept and its limitations (see Dekker videos above)
- Just Culture or Fair Culture frameworks (see the ‘Just Culture’ section on this page)
- Mind traps or cognitive biases and decision-making
- An investigation ‘mindset’
Besides this training in human factors, all investigators should also receive training in:
- Company investigation, analysis and reporting procedures
- Conducting interviews (such as asking ‘open’ questions, active listening, awareness of body language and note-taking)
- Other data collection approaches besides interviews
- Root cause analysis techniques
- Recommending suitable actions
- Effective communication of findings and influencing others.
The Field Guide to Understanding ‘Human Error’ (3rd Edition, 2014). Whilst I usually provide links to freely-available resources, I make an exception in this case. The marketing material for this book states that: ‘This latest edition of The Field Guide to Understanding ‘Human Error’ will help you understand how to move beyond ‘human error’; how to understand accidents; how to do better investigations; how to understand and improve your safety work’. Very highly recommended. Sidney provides a 5-minute video-briefing on this book here.
Learning from incidents, accidents and events, Energy Institute (2016). Learning From Incidents (LFI) is a process whereby employees and organisations seek to understand any negative events that have taken place and then take actions in order to prevent similar future events. This publication (free download when you register) covers the whole LFI process, from reporting and finding out about incidents, through to implementation of effective learning and resulting in changing practices. It guides the reader to understand the human and organisational factors (HOF) causes of an incident through appropriate investigation approaches. This document replaces Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents (2008).
Human factors in accident investigations, National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA, 2016). This information paper seeks to facilitate improvement in the quality of exploration of human factors contributions during investigations, and so contribute to the development of more effective corrective actions. It provides a suggested approach to exploring human factors contributions within accident and dangerous occurrence investigations. Written for the Australian offshore petroleum industry, but applies more widely.
Human factors in accident investigations. Extract from UK HSE Inspectors Human Factors Toolkit. Outlines an accident model and provides a series of test-yourself audit questions.
Investigative interview guidance, National Patient Safety Agency, 2008. This interview style is also known as the cognitive interview, based on psychological theory and research for examining the retrieval of information from memory. Although written for patient safety incidents, this short guide is a useful reference for anyone wanting to improve their interview technique.
Learning, candour and accountability. Care Quality Commission (2016). A year after a review commissioned by NHS England uncovered failings at Southern Health Foundation Trust, the CQC reviewed how UK healthcare Trusts investigate and learn from the deaths of people who have been in their care. It examines whether opportunities for prevention of death have been missed, and identify any improvements that are needed. The CQC weren’t able to identify any trust that demonstrated good practice across all aspects of identifying, reviewing and investigating deaths, and ensuring that learning is implemented. Several of the recommendations apply to all industries. The CQC press release can be found here.