3124 Human factors briefing note no. 15 – Incident and accident analysis

Overview:

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The terms ‘incident’ and ‘accident’ are often used interchangeably, however, incident can refer to both ‘near misses’ or accidents. Incidents (near-misses) and accidents happen at the end of a chain of events. Very often, the immediate cause, just before the accident, is a human failure of some kind. But before that, there will be other actions, decisions or events that influence the failure. By finding these underlying causes – the human and organisational factors described in these briefing notes that influenced the failure – it may be possible to prevent future similar accidents.

Why incident and accident analysis?

“Many accidents are blamed on the actions or omissions of an individual who was directly involved in operational or maintenance work. This typical but short-sighted response ignores the fundamental failures which led to the accident. These are usually rooted deeper in the organisation’s design, management and decision-making functions”. Source: HSE (1999), Reducing error and influencing behaviour, HSG48.

Incident and accident analysis (hereafter referred to as incident analysis) is, in many cases, carried out at a superficial level in a wide range of industries. Some analyses conclude that the cause of an incident was ‘human error’. They may go further and identify that the human error was a result of lack of training, with a typical remedial action being to retrain the person involved in the incident. In terms of modern safety management, there should be a more thorough analysis. Such an analysis ignores the fundamental question ‘why’ was training, in this case, lacking?

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