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Learning from incidents, accidents and events

When an accident, incident or unwanted event happens, we ask 'why did it happen?'.  The causes of incidents stem from human and organisational factors (HOF) - meaning that HOF knowledge is vital to understanding why incidents happen and how to prevent them.

In 2008, EI published Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents (now superseded), a well-read and respected publication that aimed to draw attention to the importance of HOF in incident investigation and analysis.  Whilst this has now been superseded, download the accident investigation article written by Bill Gall for the Dec. 08 issue of Petroleum Review to get an overview.

In 2014, the EI Human and Organisational Factors Committee (HOFCOM) had the opportunity to revisit and update the 2008 publication.  Along with the Stitching Tripod Foundation (STF), who had recently partnered with the EI, EI consdered there to be a gap in guidance for a number of phases in the learning from incidents (LFI) lifecycle – in particular, ‘learning’ itself.  For example, there is a wealth of guidance available on incident investigation, however organisations often struggle with the activities before investigation – reporting and prioritising incidents for investigation, overcoming legal obstacles – and what comes after the investigation – creating recommendations, communicating, and embedding and sustaining learning.

Published in August 2016, Learning from incidents, accidents and events replaces the 2008 guidance, and has been renamed and published as its own 1st edition to reflect its broader scope.  Whilst retaining the information from the 2008 guidance, it expands upon the previous guide’s content significantly (see table below for comparison of content between the two publications): 

Learning from incidents, accidents and events (2016)

Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents (2008)

Number of pages (not including Annexes): 98

Number of pages (not including Annexes): 22

1 Introduction

1 Introduction

2 Overview of incident causation and LFI

2 Human factors, safety management and safety culture

3 Reporting and prioritisation

3 Lifecycle of an incident or accident investigation

4 Investigation: fact finding

5 Investigation: analysis

6 Recommendations and actions

7 Broader learning

8 LFI evaluation

Annex C: Performance influencing factors

4 Key factors influencing human failure

Retained on website > >

Annex A: Selecting an appropriate method

Retained on website > >

Annex B: Brief descriptions of methods

Drawing upon not just literary sources but also three industrial workshops held in 2014, attended by regulators, energy industry representatives, representatives of other industries, academia and specialist consultants, this publication:

  • Covers the entire LFI lifecycle in some detail, including incident reporting, investigation, creating recommendations, broader learning (i.e. communication and embedding learning), and evaluating whether learning has been successful.
  • Has a large focus on learning.  Throughout, the guidance tries to help the reader to understand and overcome the ‘blockers’ to learning, and to tailor LFI activities towards learning rather than other objectives. Tables of ‘blockers’ and ‘enablers’ to learning are provided for each phase of the LFI lifecycle.
  • Provides case studies of how other organisations have improved LFI.
  • Provides a management summary in order to give senior executives an overview of the blockers to learning.

Whilst the guidance does provide a wealth of information, it does not unnecessarily duplicate information available elsewhere.  It aims to be the first point of call for those looking to find out about LFI, but points to more specific and detailed resources where they are available.

How to access this publication

Learning from incidents, accidents and events (free download to registered users - registration is free - or priced hardcopy publication)

Further resources

25 October 2016 launch event presentations: This publication was launched with a 1 day workshop 25 October 2016.  The presentations can be downloaded above, and videos of the event viewed online:

2008 guidance: Annex A: Selecting an appropriate method, and Annex B: Brief descriptions of methods
A major component of the 2008 guidance was the descriptions of 28 incident investigation/analysis methodologies, covered in Annexes A and B.  Although no longer included in the 2016 guidance, these Annexes have been retained on the EI website as being of potential value.  However, note that they are no longer officially supported by the HOFCOM and will not be updated or corrected over time.  Therefore the information may be out of date, and is to be used only at the reader's risk.

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.