Nine (9) principles for incorporating human factors into LEARNING investigations:
1) Be prepared to accept a broad range of types and standards of evidence.
Organizations that are genuinely seeking to learn from incidents are prepared to accept the need for action and change based on informed judgments, rather than necessarily hard “evidence,” about why people at the sharp as well as the blunt end of the organization may have behaved and acted in the ways they did.
2) Seek opportunities for learning beyond actual loss events.
Near misses, close calls, anonymised reporting systems, and sensitivity to weak signals from operations all provide learning and continuous improvement opportunities.
3) Avoid searching for blame.
Focusing on individual failure and blame creates a culture of concealment and reduces the likelihood that the underlying causes of events will be identified.
4) Adopt a systems approach.
Serious adverse events can only be understood in terms of the overall socio-technical system in which the event occurred. That means understanding and being open to the possibility of a need for change in any of the components of the system. Investigating why the controls the organization thought it had in place were not effective in preventing the event can bring a lot of insight and learn about systemic issues.
5) Identify and understand both the situational and contextual factors associated with the event.
Look beyond individual performance and actions, and explore the complex interplay between psychological, social, and organizational factors influencing decisions and actions. Consider how interactions between situational and contextual factors could lead to unexpected or undesirable human performance.
6) Recognize the potential for differences between how work is imagined and how work is actually done.
Investigators must be sensitive to the fact that “work-as-done” often diverges significantly from how work is documented in formal procedures, disclosed, or prescribed. The goal of learning is to improve work-as-done and then seek to align better how this is more accurately described and represented in formal procedures.
7) Accept that learning means changing.
Lessons identified (the complex interplay between the underlying factors identified) in an investigation report are not the same as lessons learned. Nothing has been learned if nothing changes in how the people in the organization think, behave, or react to future events and situations. Though change does not mean effective learning – change must be effective in implementing the intent of recommendations, must be understood and accepted by those affected, and must be embedded so it is sustained.
8) Understand that learning will only be enduring if the change is embedded in a culture of learning and continuous improvement.
This means an open and fair culture where people value and is motivated to learn and make changes for the better and where the entire organization is engaged in the learning process; learning and change are considered normal. If an organization is defensive, learning will be inhibited.
9) Do not confuse recommendations with solutions.
Recommendations should set out what improvement is needed without defining how that improvement is to be achieved. Solutions are concerned with satisfying recommendations in a practical, effective, and sustainable way. Good recommendations allow the opportunity for a range of solutions. Recommendations should be linked to system performance so that the change’s reason remains understood as the solution is developed and implemented.
Source: LEARNING FROM ADVERSE EVENTS