Incident Investigation

The outcome: The Keil Centre’s recommendations for addressing human error and non-compliance were incorporated into the investigation report. We also made observations on the maturity of the safety culture at this site.​

The approach: Evonik has been using HFAT® for many years and is striving to ensure that its investigators are masters of the tools. Experienced users submitted a sample of investigations for our experts to review. We then gave one-to-one coaching to individual investigators to provide further guidance on all aspects of their investigation, from evidence gathering through to recommendation writing. The sessions also provided the opportunity for the investigators to ask specific and focused questions about the tool outside the classroom and get specific feedback.

The outcome: Evonik now has a number of internal investigators who have been through this process and are leading on some of the more difficult and complex investigations within the company. We have seen the quality of the human error investigations increase significantly over the period that the programme has been operating.

The issue: An organisation with a number of investigators trained in the Human Factors Analysis Tools (HFAT®) wanted to develop internal expert users to help other investigators improve their own analyses.​

The approach: The company selected six HFAT®-trained investigators who had conducted HFAT® analyses. Their analyses and supporting evidence were reviewed by the Keil Centre human factors and incident investigation experts. Each investigator received a one-to-one coaching session to provide feedback on their analysis work as well as guidance and strategies for improving their analyses in the future.

The outcome: Several of the investigators who took part in this process have been deemed as experts in the tools within their company and are providing guidance to those who are less experienced.

The issue: At an industrial site in the UK, an incident occurred during a routine cleaning operation that resulted in the loss of a large volume of vapour-forming, flammable material. The company’s initial investigation work identified several critical factors that required more detailed Human Factors analysis. The Keil Centre provided focused Human Factors Support to help analyse critical behaviour and provide recommendations.

The approach: Our expert consultant reviewed the evidence collected so far with investigation team members, conducted a series of interviews and collected additional evidence. This information was used to support a Human Factors Analysis Tools (HFAT®) analysis and guide the recommendations. Our consultant then compiled a summary report and presented the results to the investigation team and managers.

The outcome: Our support and analysis helped to explain the behaviour that led to the incident and the factors that influenced it. Although this had initially appeared to be a deliberate behaviour, the balance of evidence revealed that a decision-based error was a better explanation. This meant that the recommendations needed to be different to help achieve sustainable improvement.

The company addressed Human Factors in good time, which allowed more flexibility in gathering supporting evidence and conducting interviews. Using a structured analysis approach, working collaboratively and discussing the analysis enabled the company to avoid the effect of cognitive bias and maintain objectivity.