Investigation of road traffic accident should be accomplished based on human factors engineering (ergonomics) consideration, which is mostly has been ignored. This presentation helps people to be more familiar with. Also, it could be useful for traffic managers to deeply go through the real causes of driver error.

2. Death rates from road traffic accidents by country
per 100,000 inhabitants (WHO 2012)
2

3. 3

4. 4
Road Environment
Factors 28%
Vehicle Factors 8%
Source: NSE Road and Traffic Authority, 1996.
Human
Factors 95%
67%
24%4%
4%
4%

5. Unsafe
Behavior
Intention
Incorrect
Intention
Correct
Lapse
Slip
Mistake
Violation
Errors
Risk Taking Behavior
Decision
Interpretation
Execution5

6. Current
understanding
Control/
Selection
Response
Feedback
External events
6

7. 7

8. 2016:
Human Factors in the Chemical and Process
Industries
Edmonds J, editor. Human Factors in the Chemical and Process Industries: Making it Work in
Practice. Elsevier; 2016 Sep 17.
Ch 8:
Human factors in incident investigation
E. Novatsis and J. Wilkinson
8

9. 1. Reporting of the incident
2. Setting the investigation terms of reference
3. Mobilizing the investigation team
4. Investigating and collecting evidence (including planning
and carrying out interviews)
5. Establishing a timeline of events
6. Conducting the analysis
7. Formulating the recommendations
8. Providing feedback and reporting
9. Implementing the recommendations (including checking
they are completed and sustained)
10. Sharing the learning
9

10. Common FailingsInvestigation Stage
• Not reported quickly enough, compromising accurate information
being collected; for example, due to people’s memory fading
Reporting
Common FailingsInvestigation Stage
• Not reported quickly enough, compromising accurate information
being collected; for example, due to people’s memory fading
Reporting
• Exclude looking at human and organizational issues
• Findings are specified in advance
Terms of reference
Common FailingsInvestigation Stage
• Not reported quickly enough, compromising accurate information
being collected; for example, due to people’s memory fading
Reporting
• Exclude looking at human and organizational issues
• Findings are specified in advance
Terms of reference
• Human factors expertise is not included in or available to the
• investigation team
Mobilization
Common FailingsInvestigation Stage
• Not reported quickly enough, compromising accurate information
being collected; for example, due to people’s memory fading
Reporting
• Exclude looking at human and organizational issues
• Findings are specified in advance
Terms of reference
• Human factors expertise is not included in or available to the
• investigation team
Mobilization
• Major assumptions are made on why people behaved as they did
and these are not challenged within investigation team
• Interviews are not planned
• Key people not interviewed or badly interviewed
• Evidence is not corroborated with other data
Investigation and
evidence collection
10

11. Common FailingsInvestigation Stage
• Intentional/unintentional distinction not made
• Search for blame conducted
• Human factors that influenced performance are not identified
Timeline and
analysis
Common FailingsInvestigation Stage
• Intentional/unintentional distinction not made
• Search for blame conducted
• Human factors that influenced performance are not identified
Timeline and
analysis
• Poor symmetry between behavioral causes and recommendations
• Unrealistic or impractical recommendations made
• Reasons for the recommendations are not made
• sufficiently clear
Recommendations
Common FailingsInvestigation Stage
• Intentional/unintentional distinction not made
• Search for blame conducted
• Human factors that influenced performance are not identified
Timeline and
analysis
• Poor symmetry between behavioral causes and recommendations
• Unrealistic or impractical recommendations made
• Reasons for the recommendations are not made
• sufficiently clear
Recommendations
• Findings challenged without due cause, especially when they
highlight management failures
Feedback/reporting
Common FailingsInvestigation Stage
• Intentional/unintentional distinction not made
• Search for blame conducted
• Human factors that influenced performance are not identified
Timeline and
analysis
• Poor symmetry between behavioral causes and recommendations
• Unrealistic or impractical recommendations made
• Reasons for the recommendations are not made
• sufficiently clear
Recommendations
• Findings challenged without due cause, especially when they
highlight management failures
Feedback/reporting
• Lessons not shared with all relevant parties
• Little thought given to the method used to share the lessons
• Underlying organizational factors are not identified or shared
Sharing learning
11

12. •ATHEANA
•CREAM
•HEART
•HEIST
•HEPI
•HET
•SHERPA
•TRACEr
12