Utilizing the Human, Machine, and Environment Matrix in investigations.

Area of Science:

• Industrial Safety
• Human Factors Engineering
• Process Management

Background:

• Incident investigations are often incomplete if root causes are not clearly identified.
• Effective corrective actions require a comprehensive understanding of how incidents occur.
• Human-machine interaction's impact on process design is well-documented.

Purpose of the Study:

• To emphasize the necessity of a complete understanding of incident causation.
• To highlight the importance of considering human-machine interaction in incident investigations.
• To advocate for the integration of human factors into the investigation process.

Main Methods:

• Review of existing literature on incident investigation and human factors.
• Analysis of the common shortcomings in current investigation practices.
• Emphasis on the principles recommended by organizations like the National Safety Council.

Main Results:

• Many investigations fail to fully elucidate the causal chain of events.
• Incomplete investigations hinder the implementation of effective corrective measures.
• The role of human-machine interaction is frequently overlooked in incident analysis.

Conclusions:

• Incident investigations must thoroughly address the 'how' and 'why' of an event.
• Incorporating human-machine interaction and environmental factors is essential for complete investigations.
• Complete investigations ensure that corrective actions are based on a full understanding of the incident's origins.