Do investigations in your organisation get to the underlying human and organisational contributions? Does your organisation have people with the right skills and with access to the right methods to investigate these factors?
Most organisations have a process for incident analysis, which typically includes some form of root cause analysis to determine the immediate and system causes for accidents, incidents and near-misses. Many organisations have a structured process which is very effective at identifying what happened and addressing technical failures. However, there is often a gap in identifying why people behaved as they did, and therefore recommendations have limited influence on organisational practices and future behaviour.
The Keil Centre has worked with many organisations to build the capability of investigators in human factors analysis. Our experience has been that training investigators in cognitive-based interviewing and in specific methods to analyse behaviour can significantly improve the quality of investigations. The method used by The Keil Centre to train investigators is called the Human Factors Analysis Tools (HFAT®) and it involves understanding the human behavioural root causes of incidents. It uses a categorisation of human failures as being unintentional behaviours (Sensory, Memory, Decision Making, and Action errors) and intentional behaviours. Analysing behaviours to this level of detail enables investigators to make more targeted recommendations to prevent incident reoccurrence.
For more information about understanding what is involved with human factors in incident investigations, or for support to investigate incidents please contact Nicole Gray (firstname.lastname@example.org).