Proceedings of the

The 33rd European Safety and Reliability Conference (ESREL 2023)
3 – 8 September 2023, Southampton, UK

A Guide for Identifying Human Factors in Accident Investigations

Stig Wingea, Stine Skaufel Kilskarb and Stig Ole Johnsenc

SINTEF Digital, Trondheim, Norway.


SINTEF Digital has recently developed a first edition of a guide for Human Factors in accident investigations to be used by The Petroleum Safety Authority, Norway. This paper provides a description of the work that has been conducted in developing the guide, as well as a description of the guide itself. It is underlined that that the aim of the guide is to support the investigation team in identifying why involved persons acted as they did to learn from the incident, and thus not to identify scapegoats. Furthermore, investigation of Human Factors must be an integrated part of the total investigation approach. That is, mapping of the cause of events, mapping of causal factors, analysis, and recommendations for follow-up of the enterprise. The guide is based on an overall model that consists of three main elements: I) decisions and actions, II) situation awareness, and III) performance shaping factors. It also includes samples of questions to help the investigation team. The paper concludes with some thoughts on strengths and limitations of this approach compared to The Human Factors Analysis and Classification System (HFACS), recommendations on combining this approach with HFACS, and further development of the approach.

Keywords: Accident investigation, Human factors, (Distributed) Situation awareness, Performance shaping factors, HFACS.

Download PDF