Supporting Site Investigation Team
May 8, 2020
The issue: The Keil Centre was asked to deploy human factors specialists to assist in the investigation of a serious incident.
The approach: The Keil Centre worked as part of the investigation team and conducted human factors analyses on a number of behaviours involved in the incident. Witness interviews, physical evidence, photographs and management testimony were all used in combination with our Human Factors Analysis Tools (HFAT®) to help determine why people behaved the way that they did.
The outcome: The Keil Centre’s recommendations for addressing human error and non-compliance were incorporated into the investigation report. We also made observations on the maturity of the safety culture at this site.