Accident investigations should consider why human failures occurred. Finding the underlying (or latent, root) causes is the key to preventing similar accidents.
Extract from inspectors human factors toolkit - Accident investigations
Further guidance
- Guidance On Investigating and Analysing Human and Organisational Factors Aspects of Incidents and Accidents
Published By Energy Institute, London, May 2008. ISBN 978 0 85293 521 7. This publication is aimed at anyone who is involved in an incident/accident investigation or analysis - either as the lead investigator or part of the supporting team. It has been developed following an extensive review of the literature on accident investigation, as well as from interviews and discussion with users and developers of these investigation and analysis methods. HSE contributed both technically and financially to the development and dissemination of this publication. - Reducing error and influencing behaviour (HSG48), HSE Books 1999, ISBN 0 7176 2452 8. Essential HSE generic industry guidance on human factors - a simple introduction
- Lessons from Longford: the Esso Gas Plant Explosion, Andrew Hopkins, CCH Australia Ltd, 2000,
ISBN 1 86468 422 4
(Available quickest via e-mail - [email protected] or available in UK via Croner CCH, 145 London Road, Kingston upon Thames, Surrey KT2 6SR: email [email protected] or Tel 0161 6436133 (or 0208 547333 or 0845 2415719).
Excellent and clear summary of main issues arising from the incident including the widespread over-focus on personal safety matters and personal safety KPIs on major hazard sites.