GETTING TO GRIPS WITH

THE HUMAN FACTOR

– an insight

The puzzle that is safety management

and total incident prevention

UK P&I CLUB
 GETTING TO GRIPS WITH THE HUMAN FACTOR

The cost of human error

The UK Club identified in its first Analysis
of Major Claims in 1990 that ‘human error’
accounted for 58% of all its claims over
US$100,000. In the years since, despite
marked falls in certain identified causes (for
instance, structural failure), human error
has remained stubbornly high as the prime cause of accidents and claims.
As a consequence, the Club has for some years sought a methodology for
both defining and analysing human error in the maritime context, in the
hope of finding ways of tackling this seemingly intractable problem.

A close study of the work of researchers at Manchester and Leiden

Universities in the 1990s, on behalf of Shell, has resulted in the Club
adopting their methodology and producing its most complex DVD to-date
in order to illustrate the underlying concepts.

The DVD No Room for Error graphically illustrates a

proven methodology that shipowners can use to
identify the propensity for human error to arise in their
shipping operations. It also gives the Club the tools with
which to analyse its extensive statistics to show where –
and why – human error is most likely to arise.

No Room For Error seeks to differentiate between the acts and omissions of
people at the sharp end, and latent system faults generated by the culture
created and the decisions made by those in authority in the shipowner’s
offices. Unlike the Club’s previous videos and publications aimed at
addressing trade specific issues, No Room for Error is intended to form part
of, or to supplement, a company’s long-term training programme as well
as to stimulate debate within the company aimed at reinforcing the

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GETTING TO GRIPS WITH THE HUMAN FACTOR

effectiveness of the ISM Code through the development of a permanent

and robust safety and environmental protection culture.

Although the DVD can be viewed on its own, and its lessons partially
absorbed, the Club has decided to hold a series of intensive one-day
workshops in Europe and Asia, aimed at assisting Members to deal with
the advanced concepts it contains, to achieve not only a better safety
performance but also with the aim of reducing the number of all incidents
of whatever nature. The workshops will bring together the latest
developments in the fields of safety management and will encourage the
development of a ‘holistic’ approach to safety as opposed to traditional
and often fragmented measures based often on a company’s last major
incident.

No Room For Error will be shown as part of the workshop whose broad
objectives will be to:

■ Provide guidance aimed at assisting the responsible shipping

company or ship manager to establish a more effective safety
management system

■ Demonstrate that these same management principles and skills

apply equally to health, environment and reputation

■ Assist the development of a more robust industry-wide health,

safety and environmental (HSE) and total incident prevention
culture

■ Support the effectiveness of the ISM Code

■ Help meet the expectations of the UK P&I Club

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 GETTING TO GRIPS WITH THE HUMAN FACTOR

The workshop will be divided into four modules:

1 The need for safety; safety legislation and operating

procedures; establishing the HSE trilogy; reputation;
total incident prevention; certification; HSE
management systems including a ‘state-of-the-art’
example and the ISM Code.

2 Safety culture; management commitment; ‘open’ and

‘no-blame’ reporting; the mythical ‘quick-fix’; the use
of HSE ‘road-maps’; performance measurement;
understanding statistics and target setting; target
zero and the real cost of incidents of whatever nature.

3 Defining an accident. An alternative way of looking

at accidents; accident investigation and analysis;
proactive safety health checks; understanding
human error; modifying human behaviour and the
theory of sheep and wolves.

4 Risk management including health risk assessment

and environmental impact assessments; the ‘hazards
and effects management process’; qualitative versus
quantitative risk assessment; use of the ‘risk
assessment matrix’; learning from the past; generic
shipboard risks; emergency response – recovery from
‘the one that got away’ and living near the ‘edge’.

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GETTING TO GRIPS WITH THE HUMAN FACTOR

Material issued at the end of the workshop, intended to ensure that the
interest and momentum generated by the day’s work is not lost, will
include:

■ A copy of all presentation material

■ The DVD No Room For Error (video versions can be supplied on request)

■ A No Room For Error contents guide

■ A ‘train the trainers’ guide to HSE management

■ A copy of the OCIMF Marine Injury Reporting Guide

While the workshop concentrates on the broadest possible approach to

managing HSE, rather than attempt to précis its entire contents, the
following pages in this booklet offer a brief résumé of parts of the vital
sections on human error and accidents.

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 GETTING TO GRIPS WITH THE HUMAN FACTOR

Human error
Over the past two decades, there has been a growing appreciation of the
many and varied ways that people contribute to accidents in hazardous
industries, or simply in everyday life. Not long ago most of these would have
been lumped together under the catch-all label ‘human error’. Nowadays it
is apparent that this term covers a wide variety of unsafe behaviours.

Most people would agree with the old adage ‘to err is human’. Most too
would agree that human beings are frequent violators of the ‘rules’
whatever they might be. But violations are not all that bad – through
constant pushing at accepted boundaries they got us out of the caves!

Assuming that the rules, meaning safe operating procedures, are well-
founded, any deviation will bring the violator into an area of increased risk
and danger. The violation itself may not be damaging but the act of violating
takes the violator into regions in which subsequent errors are much more
likely to have bad outcomes. This relationship can be summarised quite
simply by the equation:

Violations + errors = injury, death and damage

The resultant situation can sometimes be made much worse because

persistent rule violators often assume, somewhat misguidedly, that nobody
else will violate the rules, at least not at the same time! Violating safe
working procedures is not just a question of recklessness or carelessness by
those at the sharp end. Factors leading to deliberate non-compliance extend
well beyond the psychology of the individual in direct contact with working
hazards and include such organisational issues as:
■ The nature of the workplace
■ The quality of tools and equipment
■ Whether or not supervisors or managers turn a ‘blind eye’ in order to get
the job done

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GETTING TO GRIPS WITH THE HUMAN FACTOR

■ The quality of the rules, regulations and procedures

■ The organisation’s overall safety culture, or indeed its absence

Violations are usually deliberate, but can also be unintended or even

unknowing. They can also be mistaken in the sense that deliberate
violations may bring about consequences other than those intended, as at
Chernobyl. In this case, out of the seven unsafe acts (active failures)
leading up to the explosion, six were a combination of a rule violation and
an error (a misventure). Here was a sad and remarkable case in which a
group of well-motivated and exceedingly expert operators destroyed an
elderly but relatively well-defended reactor without the assistance of any
technical failures.

The distinction between errors and violations is often blurred but the main
differences are shown in the table below:

ERRORS VIOLATIONS

Stem mainly from informational Stem mainly from motivational

factors: incorrect or incomplete factors. Shaped by attitudes, beliefs,
knowledge, either in the head or in social norms and organisational
the world. culture.

They are unintended, and may be They usually involve intended or

due to, a memory failure (a ‘lapse’) deliberate deviations from the rules,
or an attentional failure (a ‘slip’). regulations and safe operating
procedures.

They can be explained by reference to They can only be understood in a

how individuals handle information. social context.

The likelihood of mistakes occurring Violations can only be reduced by

can be reduced by improving the changing attitudes, beliefs, social
relevant information: training, norms and organisational cultures
roadside signs, the driver-vehicle that tacitly condone non-compliance
interface, etc. (culture of evasion).

Errors can occur in any situation. Violations, by definition, bring their

They need not of themselves, incur perpetrators into areas of increased
risk. risk, i.e. they end up nearer the ‘edge’.

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While errors may be simple memory or attentional failures, they can be

exacerbated by:

Routinisation – the mark of a craftsman whereby the individual becomes

so expert at exercising a particular skill, that he/she no longer
consciously thinks about it allowing the mind to wander and the
unexpected to happen – drivers who regularly travel the same route to
the station each day suffer from this – ‘am I here already?’

Normalisation – the process of

forgetting to be afraid – interestingly
most accidents on mountains
happen on the way down from the
summit – only a relatively small
number happen on the way up.

Intrinsic hazard – no matter how well you defend yourself the dangers
‘out there’ never go away – move outside your protective ‘bubble’ and
something or someone will get you!

Creeping entropy – systems, policies and procedures grow old or fail to

adjust to changing external factors thus increasing the propensity for
accidents to happen.

Murphy’s Law – if it can happen it will happen, but there is also Schultz’
Law. Mr Schultz merely said that Murphy was an optimist!

The rules
We have already spoken about breaking the ‘rules’ but what precisely are
they? Basically they are procedures written to shape people’s behaviour so
as to minimise accidents. They are, if you like, standards designed to form
part of the system defences against accidents. Defences are installed to
protect the individual, the asset or the natural environment (all ‘objects of
harm’) against uncontrolled hazards and generally appear in two forms:

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■ ‘Hard’ defences, provided by fail-safe designs, engineered safety

features and mechanical barriers.

■ ‘Soft’ defences provided by procedures, rules, regulations, specific

safety instructions and training.

‘Soft’ defences are more easily circumvented by people than

‘hard’ defences and thus constitute a
major challenge to any safety management system

To remain totally relevant and to avoid falling victim to ‘creeping entropy’,

procedures are continually being amended and updated to cover matters
such as changed working conditions, new legislation, new equipment and
most particularly, to prohibit actions that have been implicated in some
recent accident. Following an accident how often have you heard people
(usually senior) exclaim “and what did the procedures say?” It is a matter
of fact therefore that over time these procedural changes become
increasingly restrictive yet the actions necessary to get the job done
haven’t changed and often extend far beyond
these permitted behavioural boundaries.
Ironically then, one of the effects of continually
tightening-up procedures in order to improve
system safety is to increase the likelihood of
violations being committed. The scope of
permitted or allowable action shrinks to such an
extent that the procedures are either routinely violated or violated
whenever operational necessity demands. In either case, the procedures
are often regarded as unworkable by those whose behaviour they are
supposed to govern. Whereas errors can arise from various kinds of
informational under-specification, many violations are prompted by
procedural over-specification – a classic own goal you might say!

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Performance levels
Now we come to the scientific bit. Error types can be classified at three
levels:

■ At the skill-based level, we carry out routine, highly-practised tasks in

a largely automatic fashion, except for occasional checks on progress.
This is what people are very good at for most of the time.

■ We switch to the rule-based level when we notice a need to modify

our largely pre-programmed behaviour in line with some change in the
situation around us. This problem is often one that we have
encountered before and for which we have
some pre-packaged solution. It is called rule-
based because we apply stored rules of the
kind: if (this situation) then do (these actions).

■ The knowledge-based level is something

we come to very reluctantly. Only when we
have repeatedly failed to find a solution using
known methods do we resort to the slow, effortful and highly error-
prone business of thinking things through on the spot. Given time, trial
and error learning can often produce good solutions. In an emergency
however, because consciousness is also very limited in its capacity to
hold information, usually not more than two or three distinct items at a
time, our brain behaves like a sieve, forgetting some things as we turn
our attention to other matters. In addition, we can also be plain scared,
and fear (like other strong emotions) has a way of replacing reasoned
action with ‘knee-jerk’ or sometimes over-learned responses.

Classifying violations
Case and field studies suggest that violations can be grouped into four
categories namely: routine violations, optimising violations, situational
violations and exceptional violations. The relationship of these to both the

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performance levels and error types is summarised in the table below with
definitions following:

PERFORMANCE LEVELS ERROR TYPES VIOLATION TYPES

Skill-based Slips and lapses Routine violations

Optimising violations

Rule-based Rule-based mistakes Situational violations

Knowledge-based Knowledge-based Exceptional violations

mistakes

Routine violations – almost invisible until there is an accident (or

sometimes as the result of an audit), routine violations are promoted by
a relatively indifferent environment; i.e. one that rarely punishes
violations or rewards compliance – “we do it like this all the time and
nobody even notices”.

Optimising violations – corner-cutting; i.e. following the path of least

resistance, sometimes also thrill seeking – “I know a better way of
doing this”.

Situational violations – standard problems that are not covered in the

procedures – “we can’t do this any other way”. An excellent example
concerns railway shunters: the rule book prohibits shunters from
remaining between wagons when wagons are being connected. Only
when the wagons are stopped can the shunter get down between
them to make the necessary coupling.
On some occasions however, the
shackle for connecting the wagons is
too short to be coupled when the
buffers are fully extended. The job can
only therefore be done when the
buffers are momentarily compressed as
the wagons first come in contact with
each other. Thus the only way to join

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 GETTING TO GRIPS WITH THE HUMAN FACTOR

these particular wagons is for the shunter to remain between them

during the connection. The result can be fatal.

Exceptional violations – unforeseen and undefined situations – “now

this is what we got trained for”. A simple example on an oil-rig
illustrates the point: a pair of engineers were inspecting a pipeline. One
of them jumps into an inspection pit and is overcome by hydrogen-
sulphide fumes. His companion fully trained to handle such situations
raises the alarm but then jumps down to help his partner, whereupon
he too is overcome. Exceptional violations often involve the
transgression of general survival rules rather than specific safety rules.
Survivors of such exceptional violations are often treated as heroes.
Exceptional violations can also be seen as an exercise of initiative even
sometimes provoking reward if, that is, you get away with it!

Given that human beings are able to circumvent both controls and
defences with sometimes quite remarkable cunning, the problem can be
summed up as follows:

● Everyone is fallible and capable of bending the rules

● All systems have technical and procedural shortcomings
● Whatever you do, there’s always something beyond your
control that can hurt you

Finally there is the theory of sheep and wolves. Studies have identified two
sorts of people – sheep and wolves. Wolves accept rule violation as a norm,
sheep do not. This results in:

■ Sheep in sheep’s clothing

■ Wolves in wolf’s clothing
■ Sheep in wolf’s clothing

■ But the largest group are wolves in sheep’s clothing

– they haven’t violated the rules. Yet!

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Accidents
An accident or incident is an unplanned chain of events which has, or
could have, caused injury or illness and/or damage to people, assets, the
environment or reputation. Modern research has shown that the basic
components of an accident can be shown as the simple ‘formula’:

Uncontrolled hazard + Undefended target =

Unwanted event (accident)

And that by adding the concept of breached, or missing, controls and

defences a simple accident can be shown diagrammatically:

Simple accident

Hazard

Breached control

Accident

Target

Breached defence

But accidents are not as simple as this, because usually there are several
breached or missing controls and defences. More importantly almost all
accidents consist of a series of interlinking ‘events’, in which each event
becomes either a new hazard or a new target in its own right. In the
presence of further targets or hazards and new and further breaches of
defences and controls, a second event is created and so on. During

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accident investigations it is not uncommon to identify five, six or even

seven interlinking events before the final event or accident becomes a
reality.

The concept of the ‘event chain’ or ‘incident trajectory’ is shown in the

diagram below:

Simple event chain or incident trajectory

FIRST EVENT SECOND SET OF EVENTS FINAL EVENT

(ACCIDENT)

HAZARD
(ineffective
aftercare) EVENT
TARGET (partial
(operator) disability)
HAZARD EVENT-TARGET
(ignition (operator-
source) EVENT- burned)
HAZARD
TARGET (fire) EVENT
(flammable (equipment
material) damaged)
TARGET
(equipment)

Note the original (first) event resulted in a fire. In the presence of two new
‘targets’, i.e. an operator and a piece of equipment, the resultant double
event led to a badly burnt operator (injury) and damaged equipment (asset
damage). Because the immediate aftercare of the injured operator (first aid
or paramedic treatment) was ineffective (new hazard), the operator’s
injuries resulted in a partial disability (final event).

Reverting to the simple accident diagram and the ‘formula’ in the text box
on the facing page, if one of the controls or defences had not been
breached there would not have been an accident. If detected the resultant
‘near-miss’ or ‘dangerous occurrence’ could still have been reported,
investigated and acted upon as if it were the real thing.

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GETTING TO GRIPS WITH THE HUMAN FACTOR

Active failures can be viewed as the

‘straw that broke the camel’s back’

The usual mechanism, whereby controls and defences are breached, is an

unsafe act by an individual at the sharp end. Occasionally, they may be
breached by an inherent unsafe condition but these too will invariably have
been caused by the acts or omissions of people, which may be nothing
more than a simple and unintentional mistake. As has already been
mentioned, such unsafe acts or unsafe conditions are generally referred to
as active failures.

While active failures are interesting – indeed much can be learnt from them
– a lot more can be learnt, and more effective remedial measures put in
place, by addressing the sick camel in the first place.

’Conventional’ view of accidents

Accident causation – the ‘conventional view’

Hazards

Accidents
Unsafe acts ! Incidents
LTIs etc

Specific
situations Defences

Conventional wisdom (above), dictates that in order for an accident to

happen, defences of some kind will have been breached, usually by an

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 GETTING TO GRIPS WITH THE HUMAN FACTOR

unsafe act, carried out in a specific situation and in the presence of hazards
of some kind.

What changed this long-established view, which as a basis for the new
model is still correct, was some highly original research sponsored by one
of the oil-majors and carried out at two major universities, one in the UK
and one in the Netherlands. The research originally set out to establish the
role of the human being in the accident equation but very quickly
established an ‘alternative’ theory of accident causation. Because of
the triangular shape of the basic model of the theory, it became known as
the ‘Tripodian’ view of accident causation. Basically it uses the
‘conventional’ diagram shown opposite, but adds a third component
general failure types (GFTs).

This ‘alternative’ model of accident causation is shown below:

Accident causation – the ‘Tripodean view’

Manage

General
failure
Reduce types
!

Hazards !

Accidents
Unsafe acts ! Incidents
LTIs etc
Learn from
Specific
situations Defences

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 GETTING TO GRIPS WITH THE HUMAN FACTOR

Instead of being reactive,

we are becoming proactive

The research accepts that, properly investigated, there is much in a reactive

sense to be learnt from accidents. It also recognises, that unsafe acts or
active failures can be reduced using tools aimed at modifying human
behaviour. The research suggested that the problem with attempting to
learn solely from active failures is that; (a) there are potentially millions of
them; (b) they will rarely be repeated in the same way, and; (c) the
circumstances in which they occurred will never be exactly the same. More
importantly the research established once and for all that the ‘sick camel’
could be made considerably healthier by managing what are called the
general failure types (GFTs) of which there are just eleven. Using a medical
analogy, the GFTs could be considered as the vital organs of the ‘safety
body’. If properly managed in terms of their inherent health or strength,
these could actually help prevent large numbers of accidents from ever
happening at all. Once again, in medical terms it’s a bit like having a healthy
heart and preventing heart attacks, or being vaccinated against pneumonia
or ‘flu – all designed to prevent illness in the first place. Thus rather than
acting in response to an incident we seek instead to act before an incident.

The research, delved deep into the causation theory in order to establish a
concrete link between breached defences and controls, and active and
latent failures, thus the Tripod causation model was born – see diagram
below:

Policy Latent Pre- Active failures Failed system

makers !failures !conditions !(incl. unsafe acts) !defences/controls ! Incident

The interesting point about this model, is that it introduces two new
elements into the causation chain. First it provides a linking mechanism,

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known as the precondition, though sometimes referred to as the

‘psychological precursor’, between the active and latent failures.

Preconditions
are the environmental, situational or psychological
system states or states of mind
that promote or directly cause active failures

Secondly, it introduces the policy maker at the very start of the chain, thus
illustrating the clear relationship between commitment by the policy
makers at the beginning of the chain and the results at the end of the day.

No commitment =
No effective safety or HSE management system

By comparing the diagram of the Tripod causation model on the previous

page and the simple accident diagram on page 12, it should become

In summary, the Tripod causation theory is based on the premise

that all accidents, of whatever nature, nearly always have multiple
causes. The theory states that active failures, e.g. unsafe acts, do not
occur in isolation but are influenced by external factors, referred to
as preconditions. These factors, are themselves routed in failures
from elsewhere in the system – latent failures. Latent failures often
originate in decisions, or actions, made remote in time and place by
policy makers, well away from those at the sharp end. This is not an
entirely new concept – other accident causation theories have
identified ‘immediate’, ‘underlying’ or ‘root’ causes as elements in
the equation. What Tripod does differently is to connect these
causes to show that latent failures actually encourage active failures
as well as magnifying their consequences.

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obvious that the link between the two is established through failed
defences (for the target) and failed controls (for the hazard), thus the
combined accident model, known as the Tripod-BETA tree complete with
all basic components looks like this:

Policy Latent Pre- Active

makers !failures !conditions !failures

HAZARD

Failed defence
EVENT

TARGET

Failed control

Policy Latent Pre- Active

makers !failures !conditions !failures

Bearing in mind that any accident consists of a series of interlinking events,

a completed accident tree can be exceedingly complex indeed.

Active failures
Both defences and controls are breached by ‘active failures’. Active failures
are the failures close to the accident event that defeat the controls and
defences on the hazard and target trajectories. In many cases, these are
the actions of people, i.e. unsafe acts. Human errors are implicated in at
least four out of five active failures, but human error as we have already
seen is a broad term that includes a number of different sources of error.

Not all active failures are human actions. Physical failure of controls and
defences also occur due to conditions such as over-stress, corrosion or

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metal fatigue. These are often referred to as ‘unsafe conditions’. Having

said that, human actions are often implicated as contributory causes to this
form of active failure but they are not, in themselves, unsafe acts. For
instance, a designer may have failed to identify the need to use a particular
high-tensile material in a specific circumstance, thus sometime later
causing component failure.

Latent failures
As already mentioned, latent failures are the ‘vital organs’ of the safety
equation. Latent failures are deficiencies, or anomalies, that create the
preconditions that result in the creation of active failures. Management
(the so-called policy or decision makers) decisions often involve the
resolution of conflicting objectives. Decisions taken using the best
information available at that moment prove to be fallible with time. Also,
the future potential for adverse effects of decisions may not be fully
appreciated, or circumstances may change that alter their likelihood or
magnitude.

The accident-producing potential of latent failures may lay dormant for a

long time, only becoming apparent when they combine with local
triggering factors – active failures, technical faults, abnormal
environmental conditions or abnormal system states; some of which even
the best HSE management systems will have absolutely no control over
whatsoever.

Rather than dealing with an infinite number of active failures, it is

reassuring to note that there are just eleven latent failures on which to
work to ensure absolute good health.

A defining characteristic of latent failures

is that they have been present within the operation
before the onset of a recognisable accident sequence

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The eleven latent failures represent the vital organs

of the safety equation – failure to ensure their inherent
good health will increase your propensity to have accidents

The eleven latent failures, which constitute the general failure types (GFTs)
are:
■ HARDWARE
■ DESIGN
■ MAINTENANCE MANAGEMENT
■ PROCEDURES
■ ERROR-ENFORCING CONDITIONS
■ HOUSEKEEPING
■ INCOMPATIBLE GOALS
■ COMMUNICATIONS
■ ORGANISATION
■ TRAINING
■ DEFENCES

Note that ‘defences’ is the only latent failure specifically

concerned with safety
– the rest are simply good management !

Preconditions
Preconditions are the environmental, situational or psychological ‘system
states’, or even ‘states of mind’, that promote, or directly cause, active
failures. Preconditions form the link between active and latent failures and
can be viewed as the sources of human error. They are best summed up in

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the following table which shows the connection between unsafe acts and
typical preconditions.

ERROR TYPE DESCRIPTION POSSIBLE CAUSES PRECONDITION

Slip Unintended deviation Attention failure Distraction from task

from a correct plan Mis-timing Preoccupation
of action with other things

Lapse Omission/repetition Memory failure Change in nature of task

of a planned action Change in task environment

Mistake Intended action Sound rule applied in Failure to recognise

(rule-based) inappropriate to the inappropriate correct area of
circumstances circumstances application
Application of unsound Failure to appreciate rule
rule deficiencies

Mistake Erroneous judgement Insufficient knowledge Organisational deficiency

(knowledge- in situation not covered or experience – Inadequate training
based) by rule immaturity
Time/emotional
pressures

Routine Habitual deviation from Natural human Indifferent operating

violation required practice tendency to take path environment (no penalties);
of least resistance no rewards for compliance

Exceptional Ad hoc infringement of Wide variety – dictated Particular tasks or

violation regulated practice by local conditions circumstances
not planned for

Act of sabotage Deliberate violation for – –

malicious
reasons

The Tripod causation model can be further expanded to show the various
ways of learning from; (a) accidents themselves; (b) from what are called
observed unsafe acts and; (c) by proactively measuring or assessing the
state of health of the eleven GFTs.

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The Tripod incident chain and feedback loop

Observed
Indicators LTIs etc
unsafe acts

Specific
PSYCHOLOGICAL
situation

DEFENCES
ENVIRONMENTAL
DECISION GENERAL OR SITUATIONAL UNSAFE ACCIDENTS
MAKERS > FAILURE > PRECONDITIONS > ACTS (active > > AND
TYPES OF UNSAFE ACTS failures) INCIDENTS
/ / /

Failure state
Loop 3 profiling Local checks on
> adequacy of >
Loop 2 Unsafe act awareness existing defences

Loop 1 Accident reports

Note that all the improvement loops go straight back to the decision or
policy makers. Note also, the specific mention of ‘unsafe act awareness’’
which is only one of many safety tools aimed at modifying human
behaviour.

The same basic model can be used to find where in the event chain
accountabilities would normally lay, a useful factor to consider when
carrying out accident investigations (see diagram opposite).

The research led to the development of two useable tools:

a proactive safety (and HSE) health check called Tripod-DELTA and
a reactive accident investigation and analysis tool called Tripod-BETA.

Tripod-DELTA seeks to measure the inherent health of each of the eleven

latent failures and displays the information as a DELTA Profile.

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Remember, the primary purpose of an investigation

is to establish the facts surrounding an accident
with a view to preventing possible recurrences

Tripod-BETA is a highly disciplined tool, aimed at establishing the total

event tree and then each of the active and latent failures, plus their linking
preconditions. The principle differences between a ‘conventional’
investigation and an accident investigation carried out in line with the
Tripod methodology is summarised in the table overleaf.

The Tripod causation path shows where to look

Fallible By top level

decisions decision makers

Latent By line management,

failures designers, planners

Preconditions By line managers,

supervisors

Active By operators,
failures maintenance crews

System
controls and
!

defences

Investigation
path

Accident

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TYPICAL ‘CONVENTIONAL’ TRIPOD-BETA ANALYSIS

INVESTIGATION

Initial phase usually Initial phase is similar to the

concentrates on the incident ‘conventional’ process but the
site and its immediate core of a Tripod-BETA tree
surroundings, gathering facts defines the incident mechanism
concerning the event and its in terms of hazards, targets and
consequences connecting events.

The next phase of the process Failed, breached or missing

examines the circumstances of hazard and target management
the incident to identify what measures (controls and
hazard management measures defences) are then added to the
failed particularly those related core model in the second phase
to procedures. The scope may of the BETA tree building
widen during this phase to process. The result is almost a
include off-site activities. delta-wing shaped diagram.

The final phase aims to identify The final phase is to plot causal
the underlying causes of the paths against each failed or
incident very often drawing on missing control or defence i.e.
similar historic events and active failures, preconditions,
experiences sometimes in a very latent failures and decisions by
ad-hoc manner. policy makers.

The investigation may include By identifying latent failures,

organisational arrangements. root causes can then be
established and addressed.

Trainers’ guide

These two sections, Human error and Accidents, are taken from the
‘train the trainers’ guide – part of the workshop package (see page 4).
For further information, please contact your local UK Club representative.

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