Human Factors
Awareness Course for
Incident Investigators
Human Factors Awareness Course
for Incident Investigators
Background
RSSB and rail industry stakeholders have been working together over the last
few years' to develop an industry-wide strategy to increase the industry's
capability to learn from operational experience, including incidents and
accidents. Industry stakeholders commissioned RSSB to develop a training
course for rail incident investigators to promote understanding of human
factors issues in the investigation process.
Course summary
This two-day course is an introduction to human factors for incident
investigators. The course uses human factors principles to better understand
why people make mistakes, why things go wrong, and which factors can
contribute to incidents and accidents in the rail industry. The course explains
how biases in human information processing can contribute to different error
types. It also covers Network Rail's 10 incident factors and considers how
person, job and organisational factors can contribute to incidents. Case
studies from a range of safety critical industries and practical examples are
used throughout. The course provides instruction on two human factors
accident analysis techniques - the Accimap and STEP - which can be used to
structure human factors information about causal and contributory factors.
These techniques are used to develop human factors recommendations to
address the factors which contributed to an incident.
Who should attend?
The Human Factors Awareness course has been developed for incident
investigators and those with an incident investigation role. It has been
recognised that the course would also be beneficial to safety managers,
operations managers, safety advisors and safety specialists, hazard analysts,
regulators, inspectors and human factors advisors.
What are the benefits of the course?
The course has been delivered to hundreds of incident investigators across 41
railway companies. This includes train operating companies, freight operating
companies, Network Rail, infrastructure contractors, suppliers and the Office
of Rail Regulation. The full list of companies who have sent investigators to
attend the course is available at the end of this document.
We have asked these investigators how they have benefited from the course.
They reported that the course has made a positive impact to the way they
RSSB | Human Factors Awareness Course for Incident Investigators
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investigate incidents and has helped them to develop more effective human factors
recommendations. They also reported an observed change in the way their companies
approach the investigation process and how they manage human factors issues. Some of
the feedback from investigators has been:
"A very useful overview of the subject area, highlighting the value of considering
human factors in an analysis of underlying behaviours in incident investigations
and the need for greater provision of human factors awareness training."
"The better understanding I gained of how attention works enabled me to
investigate a speeding incident with more insight".
"The training has helped me to make recommendations that are more relevant
to the real reason why an incident happened. This will help to reduce the risk of
a similar incident occurring again in the future."
Course content
Section
Introduction to
Human Factors
Understanding
human
performance
2
Section overviews
In this introduction to human factors, we
consider the factors that contribute to
accidents and incidents. A model of human
factors is used which categorises human
factors into the individual, the job and the
organisation. The Swiss Cheese model of
accident causation is described which makes a
distinction between unsafe acts and unsafe
conditions. A real life case study is used to
demonstrate the unsafe acts and unsafe
conditions that contributed to the 1987 King's
Cross underground fire.
This section provides an introduction to how
people process information to make safe (or
unsafe) decisions. We explain the stages of the
human information processing system
including perception, situation awareness,
memory, decision making and action. We also
discuss how things may go wrong at each of
these stages in relation to accidents.
RSSB | Human Factors Awareness Course for Incident Investigators
Learning objectives
 Identify the three
main levels of human
factors.
 Describe the 'Swiss
cheese' model of
accident causation.
 Describe the
difference between
unsafe acts and
unsafe conditions.
 Describe the stages of
human information
processing.
Section
Section overviews
Human error and
violations
This section provides an introduction to
understanding errors and violations. People get
things wrong all the time. People simply must
make mistakes. It is a crucial part of our nature.
Without mistakes there can be no learning.
Errors are at the heart of our ability to adapt to,
and master, new situations. But some errors
have such dire consequences that they need to
be prevented. This module will explain that
human errors can result from understandable,
predictable aspects of the environment in
which we work. The module will explain the
main types of human error that can occur at
different stages of the human information
processing model. The module will also
demystify the error categories of perception
slip, action slip, memory lapse and decision
making. We will also be consider the main
types of violations and why people break rules.
Real life examples are used throughout to
show how errors and violations can occur in the
real world.
The individual
This section will give you an understanding of
influences that arise from individuals
themselves. These influences include
distraction, fatigue, physical and mental wellbeing and attitudes. These factors relate to
Network Rail's 10 incident factors in SMIS. A
case study is provided to illustrate how
motivation can affect human behaviour in
undesirable ways. The role of knowledge, skills
and experience is discussed in the context of
the KLM Tenerife collision. This considers how
even very experienced people can form
expectations that influence their situation
awareness in negative ways.
Learning objectives
 Recall the error and
violation types as
outlined in the GEM-R
model.
 Classify the different
types of errors and
violations.
 To give examples of
individual and person
factors that can
contribute to incidents
and accidents.
RSSB | Human Factors Awareness Course for Incident Investigators
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Section
4
Section overviews
Learning objectives
The job and
workplace
This section discusses performance shaping
factors at the level of the job and workplace.
The first topic covered is equipment design and
the impact on the human user, using some
examples of poor equipment design and
usability. The effects of both high and low
workload on human performance are
discussed. The complexities of communication
and teamwork are discussed, using examples
both from within and outside the railway
industry to illustrate the limitations that can
lead to misunderstandings. Rules, procedures
and methods of working are discussed in
relation to their potential contribution to
human error and violation. Finally, factors
associated with the work environment are
discussed in relation to their effects on human
performance.
 To give examples of
job and person factors
that can contribute to
incidents and
accidents.
The organisation
This section discusses performance shaping
factors at the level of the organisation. The
module begins with an overview of the
influence of organisational factors on human
performance, using a case study in the oil and
gas industry. The influence of organisational
culture, leadership and supervision are
discussed in relation to how they impact on
people's decisions and actions. Organisational
systems are discussed with regard to how they
can sometimes impede rather than support the
desired human performance. Finally, the
impact of change on human performance is
considered.
 To give examples of
organisational factors
that can contribute to
incidents and
accidents.
RSSB | Human Factors Awareness Course for Incident Investigators
Section
Section overviews
Putting it into
practice
This section provides an overview of, and
practical guidance of, two human factors
methods that can be used to analyse incidents
and accidents. The Accimap and STEP
techniques are described, with step-by-step
guidance on how to apply them. Human
factors recommendations will be developed
based on the outputs of these techniques.
Investigative
techniques
This is a handy booklet which comprises all the
practical tools and techniques covered in the
course.
Learning objectives
 To use the AcciMap or
STEP techniques to
analyse an incident.
 To develop human
factors
recommendations to
address the factors
which contributed to
an incident or
accident.
RSSB | Human Factors Awareness Course for Incident Investigators
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The RSSB Human Factors Awareness Course has been delivered to the following companies:
 Abellio Greater Anglia Limited
 Freightliner Heavy Haul Limited
 Amey Fleet Services Limited
 Freightliner Limited
 Arriva Trains Wales
 GB Railfreight Limited
 Atkins Rail Limited
 Grand Central Railway Company Limited
 Babcock Rail Limited
 Heathrow Express Operating Company
 Balfour Beatty Rail Limited
Limited
 Bombardier Transportation Limited
 Jarvis Group Limited
 Carillion Rail
 London Midland
 Colas Rail
 London Overground Rail Operations Limited
 Cross Country Trains Limited
 Mersey Rail Electrics Limited
 DB Schenker Rail Limited
 Network Rail Northern Rail
 Direct Rail Services Limited
 Office of Rail Regulation
 East Coast Mainline Company Limited
 Serco
 East Midlands Trains Limited
 South Western Trains Limited
 Eversholt Rail Group
 Southeastern Trains
 First Capital Connect Limited
 Southern Railway
 First Greater Western Limited
 The Chiltern Railway Company Limited
 First Hull Trains Limited
 Tyne and Wear Metro
 First ScotRail Company Limited
 Virgin Trains
 First Transpennine Express
 Volker Rail Group Limited
 Wrexham and Shropshire
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RSSB | Human Factors Awareness Course for Incident Investigators
Email enquirydesk@rssb.co.uk
Tel
+44 (0) 20 3142 5300
Twitter@RSSB_rail
Webwww.rssb.co.uk
Rail Safety and Standards Board
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One South Place
London EC2M 2RB