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Human and organisational factors: Incident and accident investigation and analysis

Simply attributing incidents/accidents to human error is not adequate; human factors aspects should be investigated such that lessons are learned to prevent recurrence. Each incident or accident is a learning opportunity, but one that can be wasted unless the effort put into investigating and analysing it focuses on discovering its true underlying causes rather than on the people directly involved and the immediate causes of their failure.

Whilst many petroleum and allied industry businesses investigate and analyse both incidents and accidents – whether with major hazards or occupational potential – human and organisational factors aspects are rarely addressed enough. This is particularly true for non-engineering aspects of HSE’s priority human factors issues, such as supervision and organisational culture.

The problem is compounded by the volume of tools available to investigate and analyse incidents, many of which have some good points; however, none of them presents an ideal solution.

Download the accident investigation article written by Bill Gall for the Dec. 08 issue of Petroleum Review

The Energy Institutes Human and Organisational Factors Work Group with the support of the HSE have developed a guidance document following an extensive review of the literature on accident investigation, as well as from interviews and discussion with users and developers of these investigation and analysis methods. Some of the interviewees provided worked examples or case studies illustrating how the methods are used in practice.

The publication is aimed at anyone who is involved in an incident/accident investigation or analysis either as the lead investigator or part of the supporting team. The guidance has been devised for use by the experienced or novice user although it should be of most value to those who have experience in health and safety issues.

How to access this publication

Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents (free download or priced hardcopy publication)

Investigating and analysing human and organisational factors aspects of incidents and accidents PowerPoint presentation. 
This presentation was prepared to launch Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents. It was presented to the Ergonomics Society’s Human factors in the oil, gas and chemical industries conference (Manchester, October 2008) and at the European Process Safety Centre’s Learning from accidents conference (Antwerp, October 2008). The presentation focuses on the importance of understanding root causes of incidents and accidents, in particular, human failures.