A Tool for Human Factors Accident Investigation, Classification and Risk Management


  1. Hendy, K.C.
Corporate Authors
Defence R&D Canada - Toronto, Toronto ONT (CAN)
A tool for Systematic Error and Risk Analysis (SERA), based on a solid theoretical framework provided by the Information Processing (IP) and Perceptual Control Theory (PCT) models, has been developed for investigating the human factors causes of accidents and incidents. SERA provides a structured process for identifying both active failures and the pre-conditions that led to these failures. In the context of this report, SERA is developed as a tool to help the accident investigator in populating the Canadian Forces version of the Human Factors Accident Classification System or HFACS. Yet SERA provides its own taxonomy of human factors causes and could stand alone, independent of HFACS, as both an investigation tool and as an accident classification taxonomy. Because of the strong separation between the active failures and pre-conditions that mark the points of intervention for the safety system, SERA can be extended to provide a risk management tool at both the tactical (for operators) and strategic (for managers) levels. A concept for a risk management tool is developed, based on 12 SERA factors at the tactical level and six SERA factors at the strategic level. The use of a software tool for implementing the steps of the SERA analysis is demonstrated.

Il y a un résumé en français ici.

SERA (Systemic Error and Risk Analysis);PCT (Perceptual Control Theory)
Report Number
DRDC-TORONTO-TR-2002-057 — Technical Report
Date of publication
01 Mar 2003
Number of Pages
Electronic Document(PDF);CD ROM

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