Safety Critical and High Consequence Case Studies
A new minor event system for the nuclear industry
Initially, the nuclear industry asked the team to explore a plant database for ‘human factors’. Having looked at the database, few human factors had actually been coded in any kind of articulated way. There was considerable use of ‘bucket categories’ by coders of events. Furthermore coding trials revealed the system to have low reliability in terms of inter-rater and intra-rater performance. A new Root Cause Coding system was developed which was piloted across three different establishments. This culminated in a training package being introduced for staff and management, improving plant safety.
Global Power Engineering Company
The client believed that their 20 year old incident reporting database had been under-utilised especially with regards to the coding and analysis of the natural text within the reports. The challenge set for HFAL was to retrospectively analyse a sample of text based reports and investigate human factors. HFAL designed a taxonomy for coding incident reports from human factors issues that contained codes for Error Promoting Conditions (EPCs). Utilising this taxonomy allowed HFAL to reveal that the reports were rich in human factors related information that had previously been unused and undiscovered by the client.
Case Study: Consumer Behaviour
Case Study: Health and Social Policy Work