Human factors incident investigation process

It provides an opportunity to include human factors in the incident investigation process. 

Incorporating Human Factors into the Incident Investigation Process... 

The ultimate goal is to be able to integrate all three types of analysis tool into an incident investigation process, allowing the consideration of all human factors issues together in developing the overall picture. This is akin to being able to complete all of the parts of the puzzle, and to be able to see the interactions between the three aspects of human factors. 

Another application area is the use of PIFs as part of the process of incident investigation. Any investigation which seeks to establish the imderlying causes of minor or major incidents will benefit from a systematic framework for evaluating the factors which can contribute to the human contribution to such incidents. This topic will also be discussed in Chapter 6. 

IMO. 2000a. Amendments to the Code for the Investigation of Marine Casualties and Incidents, Resolution A.884(21), Appendix 1 ThelMO/ILO Process for Investigating Human Factors. 

Once the evidence has heen collected and a timeline or sequence diagram developed, the next phase of the investigation involves identifying the causal factors. These causal factors are the negative occurrences and actions that made a major contrihution to the incident. Causal factors involve human errors and equipment failures that led to the incident, hut can also he undesirable conditions, failed harriers (layers of protection, such as process controls or operating procedures), and energy flows. Causal factors point to the key areas that need to he examined to determine what caused that factor to exist. 

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