Last reviewed 16 October 2020

The Chartered Institute of Ergonomics and Human Factors (CIEHF) has published a new White Paper on learning from adverse health and safety events such as the Buncefield oil depot fire of December 2005 and the loss of the space shuttle Challenger in January 1986.

The paper shares the knowledge and experience of a number of human factors experts in incident prevention and management.

It is designed to help organisations understand a human factors perspective to investigating and learning from adverse events, as well as provide key principles organisations can apply to capture the human contribution to adverse events.

The paper also looks at how organisations learn, and fail to learn, from adverse events. In addition, it presents practical guidance on the application of human factors in the investigation process.

Nine principles for incorporating human factors into learning investigations are identified in the White Paper as follows.

  1. Be prepared to accept a broad range of types and standards of evidence.

  2. Seek opportunities for learning beyond actual loss events.

  3. Avoid searching for blame.

  4. Adopt a systems approach.

  5. Identify and understand both the situational and contextual factors associated with the event.

  6. Recognise the potential for difference between the way work is imagined and the way work is actually done.

  7. Accept that learning means changing.

  8. Understand that learning will only be enduring if change is embedded in a culture of learning and continuous improvement.

  9. Do not confuse recommendations with solutions.

The paper is available online via the CIEHF website.