Incident Analysis

Abstract

To improve safety, work systems need to be designed that help humans successfully manage expected and unexpected situations. A resilience-based human factors method called strategies analysis for enhancing resilience (SAfER) has been developed to help practitioners identify ways to create systems that let humans more effectively control the range of different operating situations they may face. The SAfER method covers the identification of (a) critical system priorities that need to be preserved in order to sustain safe operations; (b) the range of decisions, actions, and strategies that humans might use to try to control different operating scenarios; and (c) design changes that help to promote actions that preserve safe operations and prevent or tolerate actions that might result in adverse outcomes. This paper describes the SAfER analysis conducted on an industrial crane-lift incident, and it compares the results from the SAfER analysis with those from a traditional incident investigation process. The findings from the comparison suggest that the SAfER method helps analysts identify and generate additional and potentially useful information on how the system design might be changed to improve crane-lift safety.