The focus of this aspect of a HP Programme is to identify underlying system causes which contributed to the event for targeted system learning to prevent recurrence and/or minimise consequences in the future.


  • Human error / non-compliance is not a root cause - dig deeper to underlying causes
  • The individual most proximate to an event is not the only person who contributed
  • There is never only one root cause
  • Blame and punishment have side effects and may be detrimental to learning and prevention
  • Contributing factors must be targeted and changed to prevent recurrence.

Recommendations should use the hierarchy of controls to target underlying system causes.


In order to move investigations from focusing on error and an individual’s behaviour as a root cause, the following is recommended:

  • Clearly articulate the individual’s behaviour(s) which contributed to the event
  • Identify Performance Shaping Factors (PSFs) that allowed for or promoted that individual’s behaviour.  Those PSFs include the following categories:
    • Job/workspace design factors
    • Personal factors
    • Management/System Factors
    • Organizational/Culture Factors
  • Develop recommendations guided by the Hierarchy of Controls by challenging the behaviour and whether:
    • The task central to the incident can be eliminated 
    • Engineering controls put in place to eliminate the opportunity for error
    • Engineering controls put in place to eliminate the consequences should the error occur
    • Administrative controls are strong and whether additional controls are required.
  • Learning from incidents is applied system-wide to similar tasks.

Explore the Guidance and Development sections above to find out how to apply these recommendations. To begin, we recommend going straight to Level 1 >>