ABSTRACT
In 2023, SINTEF Digital developed a guide for Human Factors in accident investigations for Havtil (The Norwegian Ocean Industry Authority). This chapter builds upon and expands a paper that describes the guide. In this chapter, we have added more details from the guide, expanded on theoretical perspectives, and clarified the approach based on an interview with Havtil in May 2025, as well as our own general experiences and reflections since the paper was published. This chapter describes the work conducted in developing the guide, as well as a description of the guide itself. The guide aims to support the investigation team in identifying why the involved individuals acted as they did, learn from the incident, and avoid scapegoating. Furthermore, investigation of Human Factors must be an integrated part of the total investigation approach. That is, mapping the course of events, identifying causal factors, conducting analysis, and providing recommendations for follow-up within the enterprise. The guide is based on an overall model that consists of three main elements: (I) decisions and actions, (II) situational awareness, and (III) performance-shaping factors. It also includes sample questions to assist the investigation team. The chapter concludes with some thoughts on the strengths and limitations of this approach compared to the Human Factors Analysis and Classification System (HFACS), recommendations for combining this approach with HFACS, and suggestions for further developing the approach.
