Human Factors
During the root cause analysis, human factors should be assessed. This text will not go into depth on human factors, but will mention a couple of poignant areas that can assist in ensuring after action root cause analysis comes to an effective conclusion, after taking into consideration all the aspects of the cause and effects of an accident/incident. James Reason (1995) conducted a study into the understanding of adverse effects – Human Factors. The following will summarise some of the major points and explain the reasoning behind human factors playing a proportionate part of any incident. The study found, major incident investigations such as Piper Alfa, Kings Cross Underground Fire, made it clear that the causes of the accidents where distributed widely within and outside the organisation. There are two types of event, active failure, an action that has immediate effects and has the likely hood to cause an accident. The second is and latent or delayed action, these events can take years to have an effect; they usually combine with triggering events then cause the accident.
- Active failures
These failures are unsafe acts (errors and violations) committed by those at the "sharp end" of the system (the actual operators of machinery, supervisors of tasks). It is the people at the human-system interface whose actions can, and sometimes do, have immediate adverse consequences.
- Latent failures
They are created as the result of decisions taken at the higher echelons of an organisation. There damaging consequences may lie dormant for a long time, only becoming evident when they combine with local triggering factors (for example, the spring tide, the loading difficulties at Zeebrugge harbour, etc) to breach the system's defences.
Decisions taken in the higher echelons of an organisation can trigger the events towards an accident becoming more likely, the planning, scheduling, forecasting, designing, policy making, etc, can have a slow burning effect. The actual unsafe act that commits or triggers an accident can be traced back through the organisation and the subsequent failures will be exposed, and discover the accumulation of latent failures within the system as a whole that led to the accident becoming more likely and ultimately happening.
To conclude, most incidents are not just about the actual events that happened, if human factors are studied during the investigation period, the actual chain of latent actions will be discovered. Consequently, better improvement action can be applied, and reduce the likelihood of the event happening again.
Read more about this topic: Incident Management
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