shappell and wiegmann, 1997 a failure analysis and classification system

Shappell and Wiegmann, 1997

A FAILURE ANALYSIS AND A FAILURE ANALYSIS AND CLASSIFICATION SYSTEMCLASSIFICATION SYSTEM

Shappell and Wiegmann, 1997

Accident & InjuryAccident & Injury

Latent Conditions

Latent Conditions

Latent Conditions

Active Conditions

Failed orAbsent Defenses

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell and Wiegmann, 1997

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ViolationsErrorsErrors

ExceptionalRoutinePerceptualErrors

DecisionErrors

Skill-BasedErrors

Shappell and Wiegmann, 1997

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

DecisionErrors

DECISION ERROR Rule-based - Misapplication of a good rule - Application of a bad rule Knowledge-based - Inaccurate or incomplete

knowledge of the problem

Shappell and Wiegmann, 1997

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Skill-BasedErrors

SKILL-BASEDERRORS

Attention Failures Memory Failure

Shappell and Wiegmann, 1997

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

PERCEPTUALERRORS

Misjudge Distance, Altitude, Airspeed Spatial Disorientation Visual Illusions

Shappell and Wiegmann, 1997

Exceptional

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ROUTINE VIOLATIONSHabitual departures

from rules condoned by management

Shappell and Wiegmann, 1997

Routine

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

Exceptional

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

EXCEPTIONAL VIOLATIONS Isolated departures from rules NOT condoned by management

Shappell and Wiegmann, 1997

Shappell and Wiegmann, 1997

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Interpersonal Resource

Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell and Wiegmann, 1997

Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Interpersonal Resource

Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Adverse Mental States

ADVERSE MENTAL STATE

Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation

Shappell and Wiegmann, 1997

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Interpersonal Resource

Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Adverse Physiologic

al States

ADVERSE PHYSIOLOGICALSTATES

Hypoxia Motion Sickness Medical Illness Intoxication

Shappell and Wiegmann, 1997

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Interpersonal Resource

Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Physical/Mental

Limitations

PHYSICAL/MENTALLIMITATIONS

Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude

Shappell and Wiegmann, 1997

Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Interpersonal Resource

Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Interpersonal Resource

Mismanagement

INTERPERSONAL RESOURCEMISMANAGEMENT

Not Working as a Team Poor Aircrew Coordination Improper Briefing Before a Mission Inadequate Coordination of Flight

Shappell and Wiegmann, 1997

Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Interpersonal Resource

Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

PERSONAL READINESSReadiness Violations

Crew Rest Requirements Bottle-to-Brief Rules Self-Medicating

Poor Judgement Poor Dietary Practices Overexertion While Off

Duty Excessive “Voluntary”

PT

Shappell and Wiegmann, 1997

Shappell and Wiegmann, 1997

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UnforeseenUnforeseen Known

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

UNSAFESUPERVISION

UNSAFESUPERVISION

Shappell and Wiegmann, 1997

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnforeseenUnforeseen Known

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell and Wiegmann, 1997

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnforeseenUnforeseen Known

InadequateSupervision

UNSAFESUPERVISION

UNSAFESUPERVISION

Known

INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance

Shappell and Wiegmann, 1997

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnforeseenUnforeseen Known

PlannedInappropriate

Operations

UNSAFESUPERVISION

UNSAFESUPERVISION

Known

PLANNED INAPPROPRIATEOPERATIONS

Improper Work Tempo Poor Crew Pairing

Shappell and Wiegmann, 1997

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnforeseenUnforeseen Known

Failed toCorrectProblem

UNSAFESUPERVISION

UNSAFESUPERVISION

Known

FAILED TO CORRECT AKNOWN PROBLEM

Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard

Shappell and Wiegmann, 1997

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnforeseenUnforeseen Known

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

Known

SUPERVISORY VIOLATIONS Not Adhering to Rules and Regulations Willful Disregard for Authority by Supervisors

Shappell and Wiegmann, 1997

Shappell and Wiegmann, 1997

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

Shappell and Wiegmann, 1997

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

ResourceManagement

ResourceManagement

ORGANIZATIONALINFLUENCES

RESOURCE MANAGEMENT Human Monetary Equipment/Facility

Shappell and Wiegmann, 1997

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

OrganizationalClimate

ORGANIZATIONALINFLUENCES

ORGANIZATIONALCLIMATE Structure Policies Culture

Shappell and Wiegmann, 1997

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

OperationalProcess

ORGANIZATIONALINFLUENCES

OPERATIONALPROCESS Operations Procedures Oversight