Analyze human factors in incidents

Investigate incidents by analyzing human performance within system design

Safety-critical industries (aviation, healthcare, emergency response, nuclear) where understanding why the operator's action was reasonable from their perspective reveals system design flaws to fix.

• · Incident narrative with actor names and actions
• · Organizational context (policies, incentives, resource constraints)
• · Environmental factors (fatigue, stress, training, communication)
• · Decision-making context (information available to operators, time pressure)

• · Swiss Cheese Model analysis (organizational influences → unsafe supervision → preconditions → unsafe acts)
• · Active vs. latent failure classification
• · HFACS taxonomy mapping (organizational, supervisory, preconditions, acts, and accident outcome)
• · Just Culture diagnosis (error, violation, sabotage with appropriate accountability)
• · HRO principle recommendations (redundancy, deference to expertise, preoccupation with failure)

• · Incident involved human operators making decisions
• · System is safety-critical or mission-critical (aviation, healthcare, nuclear, emergency response)
• · Full incident narrative reconstructed (timeline, actor context, information available)
• · Organizational policies and incentive structures documented
• · Willingness to re-examine system design, not just operator training

• · Stopping at 'operator error' without investigating system factors (Dekker 2014 anti-pattern)
• · Treating all violations as equivalent (routine vs. exceptional require different responses)
• · Ignoring latent failures introduced upstream by design/management decisions
• · Attributing perfect hindsight to operators who made decisions with incomplete information
• · Using postmortem findings to punish the operator (destroys Just Culture and reporting)
• · Confusing individual accountability with system accountability

• · James Reason's Swiss Cheese Model (1997, Managing the Risks of Organizational Accidents) — 10,000+ citations
• · HFACS (Human Factors Analysis and Classification System) adopted by FAA, NASA, NTSB for aviation safety
• · Just Culture algorithm (David Marx, GAIN) implemented across healthcare systems (medical events, medication errors)
• · Crew Resource Management (CRM) findings from 60+ years of aviation crew studies
• · High-Reliability Organization (HRO) principles from Karl Weick research on organizations that handle dangerous processes
• · Explicitly reframes 'human error' as a symptom of system design rather than terminal explanation