In the 'Why Investigate' series we have considered the why, the who, the when, and the what, all related to the incident investigation process. We have looked at some of the technical aspects of Human Factors, and you have been upgraded to better writers than me – and some only wearing their underpants ('we have a situation blog'). Big congratulations to Lara ('ethics in research' blog) for submitting her PhD thesis and Alex ('making wrong decisions blog') now president of the Chartered Institute of Ergonomics and Human Factors. A welcome to the new MSc study types who will be contributing to
Well, this sounds like I have moved from my normal citation of Greek philosophers and Classical Greek terms like ‘ergonomics’ straight through to the Avant Garde poetry of the 1950s. An error trap is an error trap. That is either profound, or Martin has got into the evidence locker again and is smoking ‘Exhibit A’. The idea I am going to advance is that an ‘error trap’ as described on the hub pages really is a simplistic trap, to trap the untrained investigator. There is, after all, a regulator of all this forensic stuff which might help here.
In 2019 (when the world was simple), I said w
Mrs Trellis of North Wales writes:
Q: Why is there no mention in your blogs about "motivation, personality, team building, and alike"?
A: Well that’s not human factors. That’s another branch of psychology called occupational psychology. These people are trained – BSc then MSc and then often four years of supervised work. Usefully for the medical profession they are registered by the Health and Care Professional Council (HCPC). If you are interested in these matters, ensure they have at least the postgraduate qualifications. The most important bit is that they abide by a code of eth
Hi Keith – all good stuff and all classic Cognitive Psychology (CP) and Human Factors (HF). Nice to read an email not about team work, non-technical skills or crew resource nonsense.
Might be worth a chat at some point?
A lot of the thinking and deciding experiments are those done in a lab and generalising them to a specific incident is a bit difficult. Where medicine is at the very beginning of CP HF journey. Looking at 50 different biases in environments that are poorly designed with lots of bespoke untested equipment may be good – but most likely for our gra
Let's start with a summary of where we are in the blogs. I’m told our reader likes the summary (a Mrs Trellis of North Wales).
In part one we decided why we investigate an incident and what an incident was. In part two we decided that two investigators (or more) collect facts together in a more accurate way than one would. In part three we gazed into each other’s eyes and concluded that facts are our friends and where they might come from. We decided interviews and photos give us good facts. In part four we were introduced to what human factors is, and what it is all about and how western
The story so far...
We investigate an incident to collect facts that will prevent the incident from occurring again (see 'Why investigate?' blog). Facts collected by two or more investigators, with enough time away from the ‘day job’, tend to be of better quality than a single person fitting the investigation in and around their other duties (see 'Who should investigate?' blog).
Human factors is a science done by science types who are trained in understanding how the limited ‘cave dweller’ tries to cope with their environment. Human factors types are not likely to have the title ‘Capt
Well done for highlighting the issue.
There is always a reluctance of humans to report things that are “not right”, and lots of my research has been about getting people to report incidents (accidents, near misses, security concerns). If things are not reported all that lovely data (evidence) that could be used for change is not available. No data = No appropriate change.
The biggest barrier to reporting is feedback, and what our – oh dear – many, many studies show is that unless the feedback is immediate, appropriate, and the input appears valued, then people don’t report. Part of
Humans have not evolved to do medicine – or deal with complex machinery or systems. For the average (HF) scientist, it’s amazing how few errors occur and how a disinterested cave dweller (aka human) can work 12–18 hours, operate a machine (in many dimensions), and still get home safely at the end of the day.
A short history of human factors
HFs is a subdiscipline of both engineering and psychology. In respect of the psychology element, it is in the tradition of western performance measuring psychology. This measurement aims to aid productivity by identifying the best of the higher pe
Being the hub HF and investigations topic lead I would say… “What’s not working, and why do you suspect that to be the case?”
I would take three or four investigations from last year and see if the interventions worked, or if the report was read, or if anyone still smiles at you! Revisit the four incidents and see if the system fails to safe, equipment is usable, and patients are now safe. Remember the only reason to do an investigation is to stop it occurring again. If the report is only used to keep a door open and nothing has changed – well let’s do something different.
You may h
Consuming tea and cake as I write this also means I can break my ‘in healthcare rule’. This rule says never say to a medical type, “well in other industries it’s done like this”. Healthcare is very different to anything else and outsiders like me should not point at other industries and say there is a panacea of methods that healthcare should use. But, placing the cup down, deep breath – what I discuss here is based on my training in incident investigation in the police (UK, US, and EU), military operations, rail, marine, aviation and security failure.
Overall, I’m starting with how I was
Mummy – Where do facts come from?
Well dear, when two investigators love each other very much (well can tolerate each other’s company for long periods of time) they do an investigation and the product is facts. Like a small child these facts bring great happiness, sadness and often inconvenient truths! These facts are messy – difficult to rationalise, have a life of their own, and will be tested by others in what appears to be out of context tests and exams. When the facts are older, both investigators will realise that they should not have been collected in the way they were. By then the
So, why do we investigate? In this part I’ll cover the philosophy of why we do it; later posts aim to provide an understanding of who might be the right person to do it. Having covered the why, I’ll do some posts about the when (always within 24 hours); the who (as in staff rather than the still-touring rock group); the what; and a few practical ‘top tips’ on the how.
Why do we investigate?
Well investigation gives jobs to us investigators and, well, that concludes my piece. Well let's at least think about the other reasons.
Organisations investigate because their regulator o