Learning more about human factors when investigating incidents

Investigating accidents and incidents is an important part of the PSA’s supervisory activities. The main goal of such inquiries is to establish causes and possible learning points. Their findings thereby help in prevention and in improving the level of safety.

Various methodologies exist for conducting investigations, and a number of different perspectives can be applied in identifying and understanding the causes of and connections in serious incidents.

Need for improvements

The quality of investigations is a key concern for the PSA. A number of reports, including one by the Safety Forum in 2019 on learning from incidents, have emphasised the need for improvements in such work by government and companies.

This study and others note that many investigation reports primarily evaluate technical and organisational factors, and devote little attention to assessing human limitations and opportunities.

The PSA has also seen a need to strengthen its follow-up of human factors in investigations. In order to gain better understanding of the incident being investigated, it must establish why people acted as they did.

That involves identifying and assessing the factors influencing performance, such as technical, human-machine, organisational and psychosocial, physical and other aspects which contributed to the incident.

The aim is not to identify scapegoats, but to acquire broader and deeper knowledge of causes and the potential for learning lessons.

Human faults or errors are seldom the sole reason for an incident. In most cases, they are only a symptom of organisational or technical shortcomings.

Strengthening and developing

A project conducted for the PSA by the Sintef research foundation in 2022 looked at ways of achieving better and more thorough follow-up of human and organisational conditions involved in serious incidents in the Norwegian petroleum industry.

The study has yielded a guidance document with an associated final report which is now being taken forward in the PSA’s commitment to strengthening and further developing its follow-up of serious incidents in the sector. This extensive process will be pursued in 2022-25.

One of the principal components in the commitment concerns continued development of the PSA’s investigation methods, which will include enhancing expertise about human factors among members of its investigation teams.