Utilizing the Human, Machine, and Environment Matrix in investigations

“How did we get into this situation?” How many times has this question been asked at the outset of an investigation, or more importantly, at the completion of an investigation? If the answer is not readily and thoroughly apparent, the investigation is not complete. Subsequently, those who will have the responsibility for correction of the conditions leading to the incident will not have all the information necessary to properly complete their task.For many years, in many writings, the Human/Machine interaction and its impact on process design has been discussed. The same impact should be examined when performing incident investigations. Consideration of the interaction of human and machine along with the environment in which they are used has long been recommended by the National Safety Council, in both design and investigation.