Norwegian Safety Authority: accident investigations need to focus on organizational factors

When investigating accidents and serious incidents, the petroleum industry places greater emphasis on human and technological factors than on organizational factors. The consequence could be that the investigation only identifies direct causes, but never finds the real, underlying causes of the accident. 

Every year, a number of undesired incidents take place on the Norwegian shelf. Several of these are serious enough for the companies to start an investigation of the incident. 

The goal of such an investigation is to uncover facts about what happened, how it could happen and what needs to be done to prevent it from happening again. 

But do the investigators get to the bottom of the causal relations? According to a new study, the answer is no. Far too often they try to identify direct causes, without adequately uncovering the underlying causes. 

The reason for this is that too little emphasis is placed on organizational factors. 

“We see that human errors and attention on the individual receive more focus than organizational factors in investigations of accidents and serious incidents,” say Hilde Heber and Siri Wiig in the PSA’s expert network for the working environment. 

The study performed by the Institute for Energy Technology (IFE) on assignment from the PSA delves deeply into investigation reports following serious incidents on the Norwegian shelf. 

The result shows that the investigations identify human and technological factors in connection with undesired incidents, but do not adequately focus on organizational factors. 

Consequently, the investigation does not result in a complete image of the causal relations, which makes it hard to prevent similar incidents from reoccurring. 

“It is important for investigations to utilize methods enabling the examination of human, technological and organizational factors. All of these factors must be examined,” say Heber and Wiig. 

There may be many reasons for mostly focusing on technical and human factors, including the competence and capacity of the investigation teams. 

Accidents and serious incidents are rarely the result of only one cause; most of them result from several, often complex and contributory causal factors. 

All players that influence the normal work process can also influence the accident scenarios, directly or indirectly. This complexity should be reflected to a greater degree in the investigation process, and there may be a need for further development to support the investigators in structuring the information and focusing on the most important aspects of the incident. 

"Searching for direct causes can yield an imprecise picture of a complex situation with composite causes."
"Organizational factors, such as cultural conditions, managerial conditions, power relations and framework conditions, can be critical to identifying the underlying causes of an incident. 

"The study shows, however, that these are factors that do not emerge as clearly in the companies' investigations,” say Heber and Wiig. 

The study Assessment of organizational factors and accident investigation measures is based on a selection of investigation reports from accidents and serious incidents in the petroleum activities over the past few years.
Most of the incidents took place on fixed and mobile facilities, while some took place on different vessel types and at land facilities. The incidents include both falling objects or objects that come loose, discharges and fires or near-fires. 

In two of the incidents, the results were personal injuries, while one resulted in a death. 

The study’s conclusions was presented and discussed at the Organizational factors in accident investigation seminar, held at the PSA’s offices on April 27.



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