All adverse events are learning opportunities. When incidents, accidents and near-misses are investigated, the human factors aspects are often not addressed in a structured manner. And simply attributing the causes to ‘human error’ is not adequate – there will usually be underlying issues that need to be identified and managed.

Investigations in all industries frequently conclude that the root causes were human error, inadequate procedures, competence, or a loss of situation awareness. However, a good investigation will identify the system deficiencies or latent failures that led to these factors.

The information presented here aims to support anyone who is involved in an investigation to understand the underlying causes of human performance issues. These articles will help to explain why people did what they did – the decisions that they made and the actions they took.

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Human factors in investigations

Human factors are reported to be contributory causes in many incidents, and yet they are often poorly addressed in accident investigations. This article outlines how to address human factors in investigations and outlines the training requirements for investigators.

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Organisations may spend a great deal of resources investigating adverse events, and so it’s important to ensure that maximum learnings are extracted. This will enable you to design systems, equipment, and work activities to better manage risk. Although mainly aimed at investigating health and safety events, the same approaches can be applied to other adverse outcomes, such as environmental, quality or productivity events.

Knowledge hub

Want to know more? See the articles below:

Human error, human performance and investigations

Human error is a central concept in ergonomics and human factors. But what is ‘human error’? Is it helping us to improve safety? The language we use may be preventing us from learning or improving.

In this article, I discuss a better way of thinking about human error.

12 questions to ask in an investigation

12 questions to ask in an investigation – getting behind the label of ‘human error’

Learning from adverse events

There are nine key principles that organisations can apply to capture the human contribution to adverse events. These principles will help you to apply human factors in the investigation process. They also demonstrate how organisations learn (and fail to learn) from adverse events.

Investigative interviewing

The article emphasizes the importance of effective witness interviews in health and safety investigations. It contrasts traditional interviewing techniques that may hinder recall with the “cognitive interview” method, which encourages free narrative and uses psychological principles to enhance memory retrieval. This approach fosters greater accuracy and supports witnesses’ psychological well-being.

Is human error a crime?

Following a medication error that led to the death of a patient, the nurse who administered the medication was sacked. Following an investigation by the Department of Health, no action was taken against the nurse or the hospital. However, following an anonymous complaint, another investigation found deficiencies in hospital systems…

Should you focus on behaviours?

A focus on individual behaviours is not the most effective approach to address workplace health and safety, unless all other necessary measures have been taken. Addressing behaviours should not be used to compensate for poorly-designed work or workplaces. This article outlines the importance of the Hierarchy of Controls to determine…

Ten facts about human failure

I find these ten facts about human failure a great way to engage delegates on human factors training courses.

This post also discusses Performance Influencing Factors, the things that make human failures more or less likely.

Remembering Trevor Kletz

Trevor Kletz was a safety hero. Over a career spanning nearly 70 years, his thoughts on human factors, human error and accident investigation helped to move the industry from a focus on individual behaviour to organisational and system failures. His proposal that we should shift from blame to learning is…

“People can forget to be afraid”

On 23 March 2005, a massive explosion and fires killed 15 people and injured another 180 at the BP Texas City Refinery, Texas. This disaster led to many investigation reports. It has been said that BP failed to learn from numerous warning signs that could have prevented the disaster. Many…

Incident investigation: Case studies

The INCIDENTS page provides summaries of high-profile events across different industries where human factors have been identified.

These investigations highlight the wide range of human factors and how they may interact to contribute to an incident.

By reviewing these incident summaries, you will gain an understanding of investigations in practice.