12．Human factor analysis method using Potential Incidents Reports

Applying the RTRI Human Factor Analysis method for analysing the underlying human factor related causes becomes time consuming when a large number of error incidents have to be examined and analysed. As such a new procedure has been developed to improve processing efficiency using potential incidents reports (Fig. 1).
In the existing method, time series contrastive analysis was applied based on the difference between “Objective required by the system” and “actual action” to identify “deviations”, whereas in the new method the object of the analysis is limited to identify errors carrying a major risk using potential incidents reports (Hiyari-Hatto).
A “Root Cause analyses (Why-Why analyses) support tool” was developed to extend the investigation into the theoretical causes leading to the detected human error.
Then, based on the analytical results of the causal analysis hand of 900 error cases and their causes, an iterative process using the question “why” is used to elucidate possible origins of the case in hand.
A “Human Factor countermeasure design flow chart” was devised to ensure that corrective measures were more than just a one-off remedy and contributed to lasting improvements in the organisation of work (Fig. 2), with additional considerations such as “raising awareness of relevant parties” etc. The process is divided into 9 steps organised in hierarchical order, aimed at ensuring that the applicable measures are feasible can be implemented in suitable conditions.
This method uses potential incidents reports for safety management system and theoretical human factor analysis aims to promote better organisation of work.