Human factors root cause determination

The mission of this independent federal agency is to investigate accidents at plant sites and determine root causes. The Board has found that the root-cause deficiencies are often within safety management systems, but can be ary factor that would have prevented the accident. Some other causes involve equipment failures, human errors, unforeseen chemical reactions or other hazards. 

Many organisations already use root cause analysis techniques that allow the identification of critical factors in the occurrence of incidents. For each critical factor, related behaviours can be isolated. A number of these factors can be related closely to human error, violation or safety culture. Formal approaches are required to perform in-depth analysis of such factors and determine the root of human factors problems and how they could be dealt with. 

The last item is very important. Too many times people will want to assign blame to individuals and discipline them. The problem with this is that experience has shown that people involved will hide evidence to avoid blame. Unfortunately, it makes it very difficult to determine root causes when this occurs. As Chapter 8 discusses, most human factor errors are really due to people being set up to fail. You have to design systems to fit around people, not the other way around. Of course legal liabilities complicate any accident investigation. 

---