Health and Safety

Executive
Human Factors
in Accident
Investigation

David Birkbeck
HID Onshore Human &
Organisational Factors Group

Health and Safety
Executive

Health and Safety
Executive
Human Factors
in Accident
Investigation
David Birkbeck
HID Onshore Human &
Organisational Factors Group
Introduction
To say accidents are due to human
failing is like saying falls are due to
gravity. It is true but it does not help us
prevent them Trevor Kletz
Aim today is to present methods that are
known to help identify human failure in
accident investigation and prevent
reoccurrence
Not a black art, a pragmatic and robust
process
What we expect
Methodical process for
gathering information,
analysing what went
wrong (and right), and
learning lessons in order
to:
Manage risk
Prevent reoccurrence
Retrospective tool, but
can be powerful in
promoting change
Accident reports
What happened
Who to
When
How it happened
But not why
Technical myopia
Failure to consider human factors
Significance of human factors
Up to 90% of accidents attributable to
some degree to human failures
...Texas CityBuncefield... Texaco
Milford Haven ... Southall and Ladbroke
Grove crashes ...Zeebruger
Proportion and significance increasing as
technical safety measures improve

Recent news
But not as simple as we think..
This accident was the result of human
error
..pilot error
Error or rule-breaking put down to
Lack of competence
Poor supervision
Not paying attention
Its not usually as simple as that!

Human failure taxonomy
Mistakes Lapses Slips
When the person does
what they meant to,
but should have done
something else
When the person
forgets to do
something
When the person does
something, but not
what they meant to do
Human failures
Unintended actions Intended actions
Errors - Unintended consequences
When the person decided to act without complying with a known
rule or procedure
Violation - Intended consequences
Slip, lapse or mistake?
Involuntary or
non-intentional
action
Was there prior
intention to act?
Did the actions
proceed as
planned?
Did the actions
achieve their
desired end?
Successful
action
Was there
intention in the
action?
Spontaneous or
subsidiary action
Unintentional
action (slip or
lapse)
Intentional but
mistaken action
Yes
Yes
Yes
Yes
No
No
No
No
How to apply
Create timeline
Identify significant behaviours
Analyse behaviours
Identify effective measures to prevent
reoccurrence
Record

Errors
Slip
When a person does something, but
not what they meant to do
Lapse
When a person forgets to do
something
Both are unintended actions with
unintended consequences
Example slip Emirates EK407
Emirates Flight EK407
Pre-flight take off calculations were based
on an incorrect take off weight (262M/t
rather than 362M/t)
This weight was entered into take off
performance software on separate laptop
Captain noticed something was wrong at
the end of the runway, took manual
control and selected maximum thrust

Example slip Emirates EK407
Example slip Emirates EK407
After the accident, Captain and First Office were
asked to resign by Emirates and did so
ATSB investigation revealed:
Captain had flown 99 hours in last month (1
hour below maximum)
Had slept for 3.5 hours in 24 hour period prior
to flight (shift rotas)
Excessively complex system for calculating
take off speed (manual transfer of information
from 2 automated systems)
No automated failsafe


Mistakes
When a person does something they
intended to do, but should have done
something else
Rule based choosing a standard solution for a
known problem the maintenance worker who
selects the wrong isolation procedures
Knowledge based working from first principles
3 Mile Island shift team dismissed a potential
explanation for the unfolding incident as they
believed a valve was closed

Mistakes
Because the action is
intended, mistakes
are much harder to
detect at the
individual level
People believe what
they are doing is right
and often dismiss
evidence to the
contrary
Bias
Tunnel vision

Violations
The Texas City technicians who filled the
raffinate splitter to 90-100% capacity
rather than 50% as stated in procedures
The Assistant Boson who was asleep
rather than checking the bow doors were
closed on the Herald of Free Enterprise
The technicians who knowingly
maintained the Chernobyl reactor in an
unsafe state to allow a safety study to be
conducted



Violations
Violation
When a person decides to act without
complying with a known rule or
procedure
Note that, in this context, there must be
an known rule or procedure
This is not a moral or ethical judgement



Violations
Violations
Note that we all integrate rule violation
into our day to day lives so the
identification of a violation should not be
regarded as a precursor to discipline
Indeed, we tend to like those who break
the rules
Violations
Violations
Types of violations
Routine
Exceptional
Acts of sabotage
The key to the effective analysis of
violations is to understand why
What antecedents were present?
What behaviour was observed?
What consequences resulted?
Performance Influencing Factors
Defined as the characteristics of the job, the
individual and the organization that influence
behaviour
Considered during behavioural analysis, often at
the end of the process
Very broad topic including a range of factors e.g.
fatigue, group effects, design of equipment,
mental wellbeing, task knowledge/complexity
A comprehensive list available on HSE website
Often have a critical role in error causation but
equally often overlooked (e.g. fatigue EK407)
Performance Influencing Factors
Can profoundly influence potential for error
(proposed nominal human unreliability). Task
is:
Routine, highly practiced, rapid task involving
relatively low level of skill (0.02)*
Miscellaneous task for which no description can
be found (0.03)*
Fairly simple task performed rapidly or given
scant attention (0.09)*
Totally unfamiliar, performed at speed with no
real idea of consequence (0.55)*
*Williams, J.C. HEART Technique
Common issues
Failure to correctly specify behaviour
The individual involved
The task they were engaged in at the time
What they did (or did not do)
What the outcome was
Making early decisions and sticking to them
As information becomes available, a mistake
can become a violation
Failure to identify the multiple behaviours
contributing to an accident or incident
Timeline critical

Why bother with any of it?
Each failure type has a different set of solutions designed
to prevent their reoccurrence. For example (not
exhaustive):
Slip/Lapse
NOT training
Hardware solutions
Cross checks
PIFs
Error
Training e.g. scenarios
Group support
Challenge
Violations
Behaviour modification
Culture improvement
What to remember
Human behaviour can be predicted with
reasonable accuracy
Correctly integrating HF into your accident
investigation process will reap rewards just
look at the contemporary causation figures
Separating error, mistake and violation
represents a highly valuable first step
Help is out there
Guidance
HSE
Industry working groups e.g. Energy Institute

A final thought
The most powerful influence on human
behaviour is outcome
Therefore managing human failure requires a
high degree of corporate honesty:
What behaviour is really rewarded?
Are we willing to look at organizational
factors, especially when we see rule
breaking?
Are we willing to make the investments that
are likely to prevent reoccurrence?
Are we willing to strive for objectivity and
pragmatism?
Sources of guidance
Reducing Error & Influencing Behaviour
HSG 48
Investigating Incidents & Accidents HSG
245
Successful Health & Safety management
HSG 65
Human Factors Website pages
http://www.hse.gov.uk/humanfactors/majorhazard/index.htm
Energy Institute guidance
http://www.energyinst.org.uk/index.cfm?PageID=1268