Human Factors in Learning from Adverse Events: The Importance of Understanding Situation and Context

The UK’s Chartered Institute of Ergonomics and Human Factors (CIEHF) recently published a White Paper on ‘Learning from Adverse Events’. The paper sets out 9 Principles representing good practice in investigating and learning about the Human Factors contribution to events. Central to those principles are the importance of understanding both the situation and the context in which people made decisions and acted. After briefly summarising the nine principles, the talk will explore in some depth the difference between what is meant by “situation” and “context” in learning from events. Using examples of major incidents for illustration, the talk will demonstrate how psychological insight can help achieve deep learning about the context of human behaviour and performance