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Investigating and analysing human and organisational factors aspects of incidents and accidents Presented by Bill Gall. New Guidance published May 2008. The Guidance was developed by the Energy Institute’s Human and Organisational Factors Working Group. See website for details

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Investigating and analysing human and organisational factors aspects of incidents and accidentsPresented by Bill Gall

New Guidance published May 2008

the guidance was developed by the energy institute s human and organisational factors working group
The Guidance was developed by the Energy Institute’s Human and Organisational Factors Working Group

See website for details

of the HOFWG’s work:


This presentation explains why new guidance is needed and introduces the document with some selected extracts including general and specific examples of problem areas



The petroleum and allied industries investigate and analyse both incidents (‘near misses’) and accidents – whether with major hazards or occupational potential, but…

  • Human and organisational factors aspects are rarely addressed sufficiently
  • That is, investigations/analyses often fail to establish root causes and thus fail to identify effective actions in response


investigation analysis

Investigation – gathering information, reconstructing events, for example, using a time-line, to make sense of the incident

Analysis – thorough and systematic review of the information to identify root causes

Investigation - Analysis

investigation analysis6

The guidance focuses on analysis but also advises on the investigation process/data gathering

  • Faults in the conduct of an investigation can make subsequent analysis difficult or its results invalid

Investigation - Analysis

hof aspects are rarely addressed sufficiently

Evidence to justify the above statement:

  • Reviewing incident investigation reports for this study and two other studies - one in the petroleum industry the other in the nuclear industry - it was not possible to establish:
  • The type of human failure involved
  • The basis for the analysts’ conclusions

“HOF aspects are rarely addressed sufficiently”

further evidence

Several incident analyses indicated:

  • Immediate Cause – Human Error
  • Root Cause – Human Error

Further Evidence

a problem with checklists

A checklist provided by a major hazard industry to assist investigators in their task proposed the following ‘root causes’:

  • Lack of competence
  • Inadequate procedures
  • Inadequate tools or equipment
  • These are not root causes: the investigator can and should continue to ask questions

A Problem with Checklists


‘Lack of competence’ – Why? What organisational processes have failed?

  • Selection procedures?
  • Methods for identifying training needs?
  • Training delivery or assessment?
  • ‘Inadequate procedures’– explain ‘inadequate’?
  • Are they difficult to find when they are needed?
  • Unclear or poorly worded/illustrated?
  • Out of date? Again, what failed here/what do we need to fix?


case study a spillage incident

A road tanker driver refuelling his vehicle left it unattended with the trigger locked.

Ten litres of diesel spilled onto the forecourt of the refuelling bay, requiring clean-up and causing delay to other drivers


Case Study – a spillage incident

example analysis of incident


The driver did not comply with company procedures for refuelling. He had left his vehicle unattended to speak to a colleague. He also stated that he had done this before without incident.

Example – analysis of incident

Why? What was so urgent?

Why? What was the ‘payoff’ for violating?

example further analysis

The investigation did not seem to explore the underlying causes of the driver’s violation.

  • Did he need something from his colleague?
  • Did he feel under time pressure and could not stop after refuelling to talk to his colleague?
  • Was he simply bored?
  • The analysis also failed to explore the issue of ‘safety culture’: the role of his colleague and other observers – why did no-one else intervene?

Example – further analysis

proposed solution

From the incident report

Driver was made aware of what can happen when not taking full care when carrying out any operation within the terminal

= “Be more careful”?

Proposed solution

better solutions

Discipline the driver and warn others about this hazardous practice

  • Explore the site’s safety culture
  • Consider removing the locking trigger on filler nozzles or add an automatic cut-off
  • BUT – removing the locking trigger could encourage drivers to improvise. An automatic cut-off could create false sense of safety

Better solutions?

learn from incident and accidents

An incident or accident has to be seen as a learning opportunity and one not to be wasted by unless the true HOF root causes are established

The more thorough the level of analysis, the better the response in terms of focused improvements

This is what you see

Learn from Incident and Accidents

This is what you don’t see – until you start to dig

improving investigation and analysis

Which investigation/analysis methods are the most useful in identifying HOF root causes?

The guidance does not tell you

The guidance provides criteria for you to choose

And before that, gives some information you will need to get the best from the methods

Improving investigation and analysis

basic understanding of hof issues

The Guidance Describes:

  • Human failure types
    • Slips, Lapses, Mistakes, Violations
    • Safety Management
    • Safety Culture

Basic Understanding of HOF Issues

a useful failure model

Direction of Events

A Useful Failure Model

Direction of Analysis

the need for a just culture

The need for a fair system of sanctions and rewards

Too punitive – reporting/cooperation will be reduced

Too lenient – complacency, low motivation conform to rules

The Need for a ‘Just’ Culture

lifecycle of an investigation

The Guidance provides advice and cautions for each lifecycle stage and advises on how best to address HOF issues. The stages are:

  • Report
  • Investigate/analyse
  • Make recommendations
  • Assign, track and close out actions
  • Share information

Lifecycle of an Investigation

brief checklists aides memoire

Key Factors Affecting Human Failure

  • Workplace – design and layout of workspace and equipment, work environment
  • Task – poorly designed, workload
  • Personnel – competence, fitness, motivation
  • Organisation – supervision/leadership, change management

Brief Checklists/Aides Memoire

selecting an appropriate method


  • Be realistic about the team’s expertise in HF; may require training
  • Checklists – can help as an initial prompt but - as shown already - can mislead the user

Selecting an Appropriate Method

criteria for selection of a method

Training requirements

  • Paper or software-based method
  • Retrospective analysis of incident reports
  • Used in petroleum industry
  • Generates graphical content e.g. timeline
  • A complete method for incident analysis
  • Provides solutions
  • Includes checklists or flowcharts

Criteria for Selection of a Method


28 methods described briefly in the Guidance

  • Included because they:
  • Were cited by interviewees as methods they had successfully used
  • Feature prominently in incident investigation literature or
  • Clearly offer a sound approach to identifying HOF aspects


further methods

6 additional methods are described but not in detail because they:

  • Do not appear to be ‘mainstream’ methods
  • But they are cited in the literature and
  • Have potential for application in the petroleum and allied industries (and others)

Further Methods

incident accident investigation analysis methods

ARCA – APOLLO Root Cause Analysis

Black Bow Ties

DORI – Defining Operational Readiness To Investigate

ECFA – Events and Causal Analysis (Charting) and ECFA+ - Events and Conditional Factors Analysis

Fishbone diagram

HERA – Human Error Repository and Analysis System

HERA-JANUS – Human Error Reduction in ATM (Air Traffic Management)

HFACS – The Human Factors Analysis and Classification System

HFAT – Human Factors Analysis Tools

HFIT – Human Factors Investigation Tool

HSYS – Human System Interactions and allied industries (and others)

Incident/Accident Investigation/Analysis Methods

incident accident investigation analysis methods29

ICAM – Incident Cause Analysis Method

MEDA – Maintenance Error Decision Aid

MORT – Management Oversight and Risk Tree

PEAT – Procedural Event Analysis Tool

PRISMA – Prevention and Recovery Information System for Monitoring and Analysis

SCAT® – Systematic Cause Analysis Technique

SOL – Safety through Organisational Learning

SOURCE™ – Seeking Out the Underlying Root Causes of Events

STEP – Sequentially Timed Events Plotting



(Kelvin) Top-Set®

Incident/Accident Investigation/Analysis Methods

incident accident investigation analysis methods30

TRACEr – Technique for Retrospective and Predictive Analysis of Cognitive Errors

Tripod Beta

WBA – Why-Because Analysis

5 Whys

Why Tree

Additional Methods

CALM – Combined Accident anaLysis Method

ISIM Integrated Safety Investigation Method


SACA – Systematic Accident Cause Analysis

STAMP Systems Theoretic Accident Modelling and Process

TOR – Technique of Operations Review

Incident/Accident Investigation/Analysis Methods

references and bibliography

The Guidance describes sources of information used including useful websites

References and Bibliography

obtaining a copy

Free download (PDF) available from

Printed copy from EI Publications online section of the Energy Institute website (£10)

ISBN 978 0 85293 521 7

Obtaining a Copy


The Energy Institute gratefully acknowledges the valuable contributions that the following individuals and companies made to this project:

Dr Kathryn Mearns Aberdeen University

Prof Rhona Flin Aberdeen University

Lee Vanden Heuvel ABS Consulting

Denise McCafferty American Bureau of Shipping

Andrew Livingston Atkins Global

John McCollom BAe Systems

Prof Graham Braithwaite Cranfield University

Les Smith DNV

Dominique van Damme Eurocontrol

Dr Barry Kirwan Eurocontrol

Rachael Gordon Eurocontrol


acknowledgements continued

Peter Ackroyd Greenstreet Berman

John Chappelow Human Factors Investigations

Dr Claire Blackett Human Reliability

Euan Dyer Kelvin Top-Set

Ronny Lardner Keil Centre

Richard Scaife Keil Centre

Prof Trevor Kletz Loughborough University

Stuart Withington Marine Accident Investigation Branch

Rainer Miller Mensch-Technik Organisation

Louise Farrell National Grid

Chris Mostyn National Grid

Dr Steve Shorrock NATS

Acknowledgements – continued

acknowledgements continued35

Rudolf Frei Noordwijk Risk Foundation

Prof Ann Mills RSSB

Declan Kielty Pfizer

Gerry Gibb Safetywise Solutions

Mark Paradies System Improvements Inc

Tjerk van der Schaaf Technical University Eindhoven

Gerard van der Graaf Tripod Foundation

Dr Linda Bellamy White Queen BV

Step Change in Safety Organisation

The Energy Institute would also like to acknowledge the HSE for their financial contribution to the development and dissemination of this publication.

Acknowledgements – continued