Introducing a human factors approach to incident investigation at the Port of Felixstowe

Port of Felixstowe (PoF) is the UK’s busiest container port, connected to the UK by road and rail. The rail terminals are managed by PoF and three freight companies operate at the Port: Freightliner, GB Railfreight and DB... [ view full abstract ]

Port of Felixstowe (PoF) is the UK’s busiest container port, connected to the UK by road and rail. The rail terminals are managed by PoF and three freight companies operate at the Port: Freightliner, GB Railfreight and DB Cargo (Hutchison Holdings, n.d.). Following a cluster of incidents, RSSB was commissioned to undertake a human factors review of the rail operation at the Port in 2014. Incidents at the Port can pose a safety risk to staff, and cause significant damage to machines and infrastructure. The report into the human factors review made fifty-seven recommendations. In 2017, the organisations at PoF asked RSSB to evaluate progress in addressing the 2014 recommendations. The focus of this paper is on the recommendations related to accident investigation.

The data were collected during interviews with managers from each organisation, review of accident investigation reports, frontline staff surveys and workshops. The objective of the manager interviews were to identify the recommendations that have been addressed. The review of accident investigation reports was to understand whether reports follow good practice in identifying both immediate and underlying factors. The frontline staff surveys and workshops identified awareness of changes, attitudes towards changes and perceived effectiveness of changes.

Interviews with managers revealed that a Joint Investigation Panel (JIP) has been formed. Representatives from the PoF and freight operators are invited to take part regardless of whether their staff had been involved in the incident. For each incident, the recommendations and actions are agreed with all parties. However, the JIPs can be resource intensive and occasionally there hasn’t been sufficient evidence to identify motivations of staff or underlying causes of the incident. 

Positive aspects of the review of incident reports included: some consideration of the underlying causes, a behavioural analysis flowchart had been used, and there were some considerations of the intentions of the persons involved. Negative aspects included: there was not always enough information about immediate and underlying causes to allow conclusions to be drawn, the intentions of key actors were missing in places and some reports showed little consideration of the underlying causes.

Survey results showed that only a minority of staff had knowledge of the JIP. There were positive perceptions for the statements related to personal responsibility and confronting colleagues about unsafe behaviours. This is encouraging and a good foundation for further improvement. A more negatively rated statement was related to reporting mistakes without fear of repercussions. Encouraging frontline staff to report safety issues is important because it allows risks to be identified before incidents occur. 

This study has highlighted that the recommendations of the 2014 study have been met with mixed success. The JIP fulfils the requirement for a neutral investigation panel, and there is a clear remit for focusing on safety learning. However, further work is required to identify immediate and underlying causes. The direction in which the companies at the Port are moving with the JIP is positive, however work needs to be completed before the JIP can reach its full potential.