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A new approach to analysing human-related accidents by combined use of HFACS and activity theory-based method

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Abstract

This study proposes a new method for modelling and analysing human-related accidents. It integrates Human Factors Analysis and Classification System (HFACS), which addresses most of the socio-technical system levels and offers a comprehensive failure taxonomy for analysing human errors, and activity theory (AT)-based approach, which provides an effective way for considering various contextual factors systematically in accident investigation. By combining them, the proposed method makes it more efficient to use the concepts and principles of AT. Additionally, it can help analysts use HFACS taxonomy more coherently to identify meaningful causal factors with a sound theoretical basis of human activities. Therefore, the proposed method can be effectively used to mitigate the limitations of traditional approaches to accident analysis, such as over-relying on a causality model and sticking to a root cause, by making analysts look at an accident from a range of perspectives. To demonstrate the usefulness of the proposed method, we conducted a case study in nuclear power plants. Through the case study, we could confirm that it would be a useful method for modelling and analysing human-related accidents, enabling analysts to identify a plausible set of causal factors efficiently in a methodical consideration of contextual backgrounds surrounding human activities.

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(adapted from Kain and Wardle 2014, p. 277)

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(adapted from Turner and Turner 2001, p. 3)

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Acknowledgments

This work was supported by the Nuclear Safety Research Program through the Korea Nuclear Safety Foundation (KORSAFe), granted financial resource from the Nuclear Safety and Security Commission (NSSC), Republic of Korea (No. 1403004). This work was also financially supported by Mid-Career Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (2016R1A2B4013710).

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Authors and Affiliations

  1. Department of Safety Standard, Korea Institute of Nuclear Safety, Daejon, South Korea

    Young Sik Yoon

  2. Department of Industrial Engineering, Chonnam National University, Gwangju, South Korea

    Dong-Han Ham

  3. Department of Industrial and Systems Engineering, Korea Advanced Institute of Science and Technology, Daejon, South Korea

    Wan Chul Yoon

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  1. Young Sik Yoon
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Correspondence to Dong-Han Ham or Wan Chul Yoon.

Appendix: Linking between the elements of activity system model and performance-shaping factors

Appendix: Linking between the elements of activity system model and performance-shaping factors

This appendix describes the PSFs matching table which links the elements of activity system model and performance-shaping factors to facilitate the effective use of the AT-based method. However, it should be noted that this is not a complete listing, rather an example of using the concepts of the AT-based method when identifying plausible causal factors.

Activity system elements

Performance-shaping factors (examples)

Subject

Personality (e.g. under-confidence, complacency, self-esteem)

Mental states (e.g. mental fatigue, stress, inattention)

Physical states (e.g. physical fatigue, illness)

Object

Number of simultaneous goals

Task characteristics (e.g. urgency, risk level, the time available)

Systems or components to be handled for a task

Subject–object

Risk perception

Domain expertize level (e.g. knowledge and skills for a job)

Negative transfer of prior knowledge or skills

Tool

(Some part of) usability of tools/equipment (e.g. visibility)

Technical failures of tools/equipment

Level of detail of procedures/documents

Technical correctness of procedures/documents

Subject–tool

Knowledge and skills of using tools/equipment/procedures

(Some part of) usability of tools/equipment (e.g. compatibility with user’s expectation)

Usability of procedures (e.g. readability, clarity)

Tool–object

Availability of tools/equipment/procedures

(Some part of) usability of tools/equipment (e.g. task difficulty)

Community

Leadership of supervisors

Team composition

Subject–community

Delegation of authority

Rewards and punishments

Community–object

The level of staffing and qualification

Teamwork for a task

Clearness in roles and responsibilities

Rule

Work practices

Adequacy of policy and guidance

Organizational customs

Div. of labour

Adequacy of coordination or communication

Level of supervision

Subject–rule

Sense of responsibility

Commitment to leadership

Community–rule

Team cohesiveness and collaboration

Team or organizational climate

Object–div. of labour

Adequacy of distributed workload

Gap between roles and capabilities

Community–div. of labour

Role awareness

Gap between roles and preference (or motivation)

Subject–another activity

(Some part of) selection and placement

Management of fitness-for-duty (e.g. drug, alcohol, fatigue)

Adequacy of training

Tool–another activity

Design control of tools/equipment (e.g. requirement, V&V)

Provision of required tools/equipment

Management of technical documents

Object–another activity

Adequacy of work planning or control

Adequacy of risk assessment

Community–another activity

(Some part of) selection and placement

Crew resource management

(Some part of) organizational change management (e.g. job rotation)

Rule–another activity

Adequacy of organizational culture assessment

Adequacy of policy making process

Div. of labour–another activity

Adequacy of protocols or methods for communication and instruction

(Some part of) organizational change management (e.g. division of responsibility)

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Yoon, Y.S., Ham, DH. & Yoon, W.C. A new approach to analysing human-related accidents by combined use of HFACS and activity theory-based method. Cogn Tech Work 19, 759–783 (2017). https://doi.org/10.1007/s10111-017-0433-3

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