The Creation of a New Minor Event Coding System
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TL;DR
A new model of the human factors component of action in this industry was created from which a model of human factors error in the same industry could be inferred, and is now being phased in within this industry.
Abstract
The present study began with an assessment of the reliability and usefulness of an existing minor event coding system in a British ‘high-consequence’ industry. It was discovered that despite the fact that the system produced replicable data, when tested in a reliability trial the causal inferences it was producing failed to meet the normal criteria for statistical reliability. It was therefore felt necessary to create a new model of the human factors component of action in this industry, from which a model of human factors error in the same industry could be inferred. A set of codes (to facilitate statistical analysis) were deduced from this last, which were then tested in a new reliability trial. The results from this trial were very encouraging, and after a six-month pilot study in which it demonstrated its usefulness as a trend and patterning tool, the system is now being phased in within this industry.