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“ “ Human beings by their very nature make Human beings by their very nature make mistakes; therefore, it is unreasonable to mistakes; therefore, it is unreasonable to expect error-free human performance.” expect error-free human performance.” Shappell & Wiegmann, Shappell & Wiegmann, 1997 1997

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Page 1: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

““Human beings by their very nature make Human beings by their very nature make mistakes; therefore, it is unreasonable to mistakes; therefore, it is unreasonable to expect error-free human performance.” expect error-free human performance.” Shappell & Wiegmann,Shappell & Wiegmann, 1997 1997

Page 2: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

0

50

100

150

200

250

300

1999 2000 2001 2002 2003 2004

0

0.5

1

1.5

2

2.5

3

Accidents LT Rate

Page 3: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Latent ConditionsBudget cuts

Excess workload

Latent ConditionsDeficient training program

Improper supervision

Latent ConditionsPoor training

Mental Fatigue

Active ConditionsFailed to ensure surface could hold

backhoe

Loss of situational awarenessFailed or

Absent Defenses

OrganizationalFactors

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Accident & InjurySunk Backhoe into

mud

Active versus Latent Failures (Reason, 1990)

Page 4: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ViolationsErrorsErrors

ExceptionalRoutinePerceptualErrors

DecisionErrors

Skill-BasedErrors

Page 5: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

DecisionErrors

DECISION ERROR Rule-based Decisions - If X, then do Y - Highly Procedural Choice Decisions - Knowledge-based Structured Decisions - Problem solving

Unsafe

Acts

Page 6: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Skill-BasedErrors

SKILL-BASEDERRORS

Attention Failures - Breakdown in visual scan - Inadvertent operation of control - Failure to see and avoid Memory Failure - Omitted item in process - Omitted step in procedure

Unsafe

Acts

Page 7: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

PERCEPTUALERRORS

Misjudge Distance, speed, weight, etc. Loss of situational awareness Visual Illusions

Unsafe

Acts

Page 8: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Unsafe

Acts

Exceptional

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ROUTINE (INFRACTIONS)(Habitual departures from rules condoned by management)

Violation of Manuals/Policies/SOPs- Failed to Inspect Equipment Prior to Use- Violated Seatbelt Policy- Failed to Comply with Tie Down Requirements- Conducted Unauthorized Procedure with Equipment- Did not Conduct Tailgate Safety Meeting- Risk Assessment not Accomplished

Failed to Adhere to Briefed Requirements Not Current/Qualified for Equipment Improper Procedure

Page 9: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Routine

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors Exceptional

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

EXCEPTIONAL(Isolated departures from the rules not condoned

by management)

Violated Manuals/Policies/SOPs- Performed Unauthorized Operation- Horseplay with Equipment- Failed to Ensure Equipment was Operational- Allowed Unauthorized Operator- Ignored Equipment Malfunction

Accepted Unnecessary Risk Not Current/Qualified for Equipment Exceeded Limits of Equipment

Unsafe

Acts

Page 10: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Crew Resource

Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Preconditionsfor

Unsafe Acts

UnsafeActs

Page 11: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & 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

Crew Resource Mismanagemen

t

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

Page 12: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators

Substandard Practices

of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Crew Resource Mismanagemen

t

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Adverse Physiologic

al States

ADVERSE PHYSIOLOGICALSTATES

Hypothermia Motion Sickness Fatigue Medical Illness Intoxication

Preconditionsfor

Unsafe Acts

UnsafeActs

Page 13: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & 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

Crew Resource Mismanagemen

t

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

Page 14: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

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

Substandard Practices

of Operators

Substandard Practices

of Operators

Preconditionsfor

Unsafe Acts

UnsafeActs

CREW RESOURCEMISMANAGEMENT

Not Working as a Team Poor Coordination/Communication Improper or No Tailgate Briefing Inadequate Coordination of Work

Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard Practices of Operators

Page 15: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & 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 ATS

Personal Readiness

PERSONAL READINESSReadiness Problems

Inadequate Rest Excess Alcohol

Consumption Self-Medicating

Poor Judgement Poor Dietary Practices Overexertion While Off

Duty Bad Habits

Preconditionsfor

Unsafe Acts

UnsafeActs

Page 16: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Page 17: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

InadequateSupervision

INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Page 18: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

PlannedInappropriate

Operations

PLANNED INAPPROPRIATE

OPERATIONS Risk without Benefit No Risk Assessment Improper Work Tempo Poor Crew Pairing

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Page 19: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

Failed toCorrectProblem

UNSAFESUPERVISION

UNSAFESUPERVISION

FAILED TO CORRECT AKNOWN PROBLEM

Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard Failure to Enforce Safety Rules

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Page 20: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

SUPERVISORY VIOLATIONS Not Adhering to Rules and Regulations Willful Disregard for Authority by SupervisorsFailure to Conduct Risk Assessment

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Page 21: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

Page 22: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

ResourceManagement

ResourceManagement

ORGANIZATIONALINFLUENCES

RESOURCE MANAGEMENT Human Budget Equipment/Facility

Page 23: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

OrganizationalClimate

ORGANIZATIONALINFLUENCES

ORGANIZATIONALCLIMATE Structure Policies Culture

Page 24: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

OperationalProcess

ORGANIZATIONALINFLUENCES

OPERATIONALPROCESS Operations Procedures Oversight

Page 25: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

Errors

PerceptualErrors

Skill-BasedErrors

UNSAFEACTS

Errors

DecisionErrors

ExceptionalRoutine

Violations

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

Substandard Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Substandard Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Adverse Physiological

States

Physical/Mental

Limitations

Adverse Mental States

Adverse Mental States

Personal Readiness

Interpersonal Resource

Mismanagement

Substandard Practices of Operators

ResourceManagement

OrganizationalClimate

OrganizationalProcess

ORGANIZATIONALINFLUENCES

Page 26: “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

““Whenever we talk about a worker who has been Whenever we talk about a worker who has been killed in an accident, we should all keep one killed in an accident, we should all keep one thing in mind. They...made a judgment. They thing in mind. They...made a judgment. They believed in it so strongly that they knowingly bet believed in it so strongly that they knowingly bet their life on it. That their judgment was faulty is their life on it. That their judgment was faulty is a tragedy,…a tragedy,…

Every instructor, supervisor, and contemporary Every instructor, supervisor, and contemporary who ever spoke to them had the opportunity to who ever spoke to them had the opportunity to influence their judgement, so a little bit of all of us influence their judgement, so a little bit of all of us goes with every worker we lose.” --goes with every worker we lose.” --AnonymousAnonymous


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