HUMAN FACTOR – Swiss Cheese Theory

FAKTOR MANUSIA DALAM K3

PERTEMUAN 6

PUTRI HANDAYANI, SKM, MKKK

PRODI KESMAS / FIKES

TUJUAN/CAPAIAN PEMBELAJARAN

Menguraikan konsep Konsep swiss cheese model, dan

Lingkup pengamatan swiss cheese model

Failed or

Absent Defenses

Organizational

Factors

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

Adapted from Reason

(1990)

Accident & Injury

Reason’s “Swiss-cheese” Model of Human Error

Errors

ACTS

Errors

Perception

Errors

Skill-Based

Errors

Judgment and

Decision-Making

Errors

Violations

Inadequate

Supervision

Planned

Inappropriate

Operations

Failed to

Correct Known

Problem

Supervisory

Violations

SUPERVISION

Resource/Acquisition

Management

Organizational

Climate

Organizational

Process

ORGANIZATIONAL

INFLUENCES

Condition of

Individuals

Cognitive

Factors

Technological

Environment

Physical

Environment

Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Perceptual

Factors

Physical/

Mental

Limitations

Adverse

Physiological

States

Skill-based Errors: kesalahan dalam tugas-tugas rutin-dilakukan

Decision Errors: kesalahan dalam pemilihan tindakan untuk situasi tertentu

Perception Errors: persepsi yang mengarah kepada tindakan yang tidak tepat

Violation: sengaja bertindak melawan kebijakan tertulis atau prosedur.

Acts The act is the end result. It answers the question of, “what happened?”

ACTS

Violations Errors

Misperception

Errors Judgment and Decision

Errors

Skill-Based

Errors

Unsafe

Acts

Unsafe

Acts

DECISION ERRORS Risk Assessment – During

Operation

Task Misprioritization

Necessary Action – Rushed

Necessary Action – Delayed

Caution/Warning – Ignored

Wrong choice of action

ACTS

Violations Errors

Misperception

Errors Judgment and Decision

Errors

Skill-Based

Errors

Unsafe

Acts

SKILL-BASED ERRORS

ACTS

Violations Errors

Misperception

Errors Judgment and Decision

Errors

Skill-Based

Errors

Inadvertent Operation

Checklist Error

Procedural Error

Overcontrol/Undercontrol

Breakdown in Visual Scan

Inadequate Anti-G Straining Maneuver

Unsafe

Acts

MISPERCEPTION ERRORS

(due to) Misjudge Distance, Altitude, Airspeed

Spatial Disorientation

Visual Illusions

ACTS

Violations Errors

Misperception

Errors Judgment and Decision

Errors

Skill-Based

Errors

Unsafe

Acts

ACTS

Violations Errors

Misperception

Errors Judgment and Decision

Errors

Skill-Based

Errors VIOLATIONS (Willful disregard for rules and instructions!)

Violation – Work-around

Violation – Routine/Widespread

Violation – Extreme

Unsafe

Acts

Physical environment: lingkungan kerja. Hujan, gelap, dingin, panas, dll

Technological Environment: alat yang digunakan dalam misi. Desain kendaraan dan kegunaan dari sistem yang terkait

Self-imposed stress: alkohol, kurang tidur, tingkat kebugaran

Prakondisi adalah hal-hal yang memungkinkan tindakan tidak aman terjadi, dan mereka menjawab pertanyaan, "Mengapa hal itu bisa terjadi?" Kategorinya adalah:

Preconditions

Condition of

Individuals

Cognitive

Factors

Technological

Environment

Physical

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Perceptual

Factors

Physical/

Mental

Limitations

Adverse

Physiological

States

Cognitive

Factors

Preconditions

for

Unsafe Acts

Unsafe

Acts

Condition of

Individuals

Technological

Environment

Physical

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Perceptual

Factors

Physical/

Mental

Limitations

Adverse

Physiological

States

PHYSICAL ENVIRONMENT Icing/Fog/Etc. on windows

Meteorological Conditions

Dust/Smoke/Etc. in Workspace

Brownout/Whiteout

Thermal Stress: Cold/Hot

Maneuvering Forces In-Flight

Noise Interference

Preconditions

for

Unsafe Acts

Unsafe

Acts

Cognitive

Factors

Psycho-

Behavioral

Factors

Perceptual

Factors

Physical/

Mental

Limitations

Adverse

Physiological

States

Technological

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Environmental

Factors

PRECONDITIONS

TECHNOLOGICAL

ENVIRONMENT Seating and Restraints

Instrument and Sensory Feedback

Visibility Restrictions

Controls and Switches

Automation

Personal Equipment Interference

Communications - Equipment

Physical

Environment Condition of

Individuals

Preconditions

for

Unsafe Acts

Unsafe

Acts

Cognitive

Factors

Technological

Environment

Physical

Environment Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Adverse

Physiological

States

Physical/

Mental

Limitations

Perceptual

Factors

COORD/COMM/PLAN Crew/Team Leadership

Cross-Monitoring Performance

Task Delegation

Rank/Position Authority Gradient

Communicating Critical Info

Standard/Proper Terminology

Mission Planning/Briefing

Miscommunication

Condition of

Individuals

Self-

Imposed

Stress

Preconditions

for

Unsafe Acts

Unsafe

Acts

Cognitive

Factors

Technological

Environment

Physical

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Adverse

Physiological

States

Physical/

Mental

Limitations

Perceptual

Factors

SELF-IMPOSED STRESS

Alcohol Physical Fitness

Drugs/Supplements/Self

Medication

Nutrition

Inadequate Rest

Unreported Disqualifying Medical

Condition

Condition of

Individuals

Preconditions

for

Unsafe Acts

Unsafe

Acts

COGNITIVE FACTORS Inattention

Channelized Attention

Cognitive Task Oversaturation

Confusion

Negative Transfer

Distraction

Geographic Misorientation (Lost)

Checklist Interference

Condition of

Individuals

Cognitive

Factors

Technological

Environment

Physical

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Perceptual

Factors

Physical/

Mental

Limitations

Adverse

Physiological

States Preconditions

for

Unsafe Acts

Unsafe

Acts

PSYCHO-BEHAVIORAL Personality Style

Pre-Existing Personality Disorder

Pre-Existing Psychological Disorder

Emotional State

Overconfidence

Complacency

Get-Home-Itis/Get-There-Itis

Overaggressive

Condition of

Individuals

Cognitive

Factors

Technological

Environment

Physical

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Perceptual

Factors

Physical/

Mental

Limitations

Adverse

Physiological

States Preconditions

for

Unsafe Acts

Unsafe

Acts

ADVERSE PHYSIOLOGICAL Effects of G Forces (G-LOC, etc)

Physical Fatigue (Overexertion)

Fatigue – Physiological/Mental

Hypoxia

Motion Sickness

Circadian Rhythm Desynchrony

Pre-Existing Physical Illness/Injury

Prescribed Meds for Injury/Illness

Condition of

Individuals

Cognitive

Factors

Technological

Environment

Physical

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Environmental

Factors

PRECONDITIONS

Perceptual

Factors

Physical/

Mental

Limitations

Adverse

Physiological

States

Psycho-

Behavioral

Factors Preconditions

for

Unsafe Acts

Unsafe

Acts

Condition of

Individuals

Cognitive

Factors

Technological

Environment

Physical

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Perceptual

Factors

Physical/

Mental

Limitations

Adverse

Physiological

States

PHYSICAL/MENTAL LIMITS Learning Ability/Rate

Memory Ability/Lapses

Anthropometric/Biomechanical Limits

Motor Skill/Coordination or Timing

Deficiency

Technical/Procedural Knowledge

Preconditions

for

Unsafe Acts

Unsafe

Acts

Condition of

Individuals

Cognitive

Factors

Technological

Environment

Physical

Environment Self-

Imposed

Stress

Coordination/

Communication/

Planning Factors

Personnel

Factors

Psycho-

Behavioral

Factors

Environmental

Factors

PRECONDITIONS

Perceptual

Factors

Adverse

Physiological

States

PERCEPTUAL FACTORS Illusions: Kinesthetic/Vestibular/Visual

Misperception of Operational

Conditions

Misinterpreted/Misread Instrument

Expectancy

Auditory Cues

Spatial Disorientation: 1, 2, & 3

Temporal Distortion

Physical/

Mental

Limitations Preconditions

for

Unsafe Acts

Unsafe

Acts

Supervision

Inadequate supervision: kurangnya bimbingan, kebijakan tertulis, atau kesempatan pelatihan

Failure to correct known problem: masalah dengan tim atau operasi

Inappropriate Operations: kurangnya penilaian risiko atau penempatan petugas yang tidak tepat

Violations: melakukan pekerjaan di luar SOP

Inadequate

Supervision

Planned

Inappropriate

Operations

Failed to

Correct Known

Problem

Supervisory

Violations

SUPERVISION

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

Inadequate

Supervision

Planned

Inappropriate

Operations

Failed to

Correct Known

Problem

Supervisory

Violations

SUPERVISION

INADEQUATE SUPERVISION Leadership/Supervision/Oversight Inadequate

Supervision – Modeling

Local Training Issues/Programs

Supervision – Policy

Supervision – Personality Conflict

Supervision – Lack of Feedback

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

PLANNED INAPPROPRIATE

OPERATIONS Ordered/Led Mission Beyond Capability

Crew/Team/Flight Makeup/Composition

Limited Recent Experience

Limited Total Experience

Proficiency

Risk Assessment – Formal

Authorized Unnecessary Hazard

Inadequate

Supervision

Planned

Inappropriate

Operations

Failed to

Correct Known

Problem

Supervisory

Violations

SUPERVISION

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

FAILED TO CORRECT A

KNOWN PROBLEM Personnel Management

Operations Management

Inadequate

Supervision

Planned

Inappropriate

Operations

Failed to

Correct Known

Problem

Supervisory

Violations

SUPERVISION

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

SUPERVISORY VIOLATIONS Supervision – Discipline Enforcement

Supervision – Unwritten Policy

Directed Violation

Assigned Unqualified Individuals

Inadequate

Supervision

Planned

Inappropriate

Operations

Failed to

Correct Known

Problem

Supervisory

Violations

SUPERVISION

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

Resource/Acquisition Management: alokasi peralatan

Organizational Climate

Process: kebijakan dan prosedur yang menunjang proses operasi

Organizational Factors The Organization is responsible for overall policy, doctrine, and allocation of

resources to the subordinate units

Organizational

Influences

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

Organizational

Climate

Resource/Acquisition

Management Organizational

Process

ORGANIZATIONAL

INFLUENCES

RESOURCE/ACQUISITION

MANAGEMENT Air Traffic Control Resources

Airfield Resources

Operator Support

Acquisition Policies/Design

Processes

Attrition Policies

Accession/Selection Policies

Personnel Resources

Information Resources/Support

Financial Resources/Support

Organizational

Climate

ORGANIZATIONAL

INFLUENCES

ORGANIZATIONAL

INFLUENCES

Organizational

Climate

ORGANIZATIONAL

CLIMATE Unit/Organizational Values/Culture

Evaluation/Promotion/Upgrade

Perceptions of Equipment

Unit Mission/Aircraft Change

Unit Deactivation

Organizational Structure

Resource/Acquisition

Management Organizational

Process

Organizational

Influences

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

Organizational

Climate Operational

Process

ORGANIZATIONAL

INFLUENCES

ORGANIZATIONAL

INFLUENCES

Organizational

Process

ORGANIZATIONAL

PROCESS Ops Tempo/Workload

Program and Policy Risk Assessment

Procedural Guidance/Publications

Organizational Training Issues/Programs

Doctrine

Program Oversight/Program Management

Resource/Acquisition

Management

Organizational

Influences

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

REFERENSI

• Chris W. Johnson, Philippe Palanqu. Human Error Safety And Systems Development. 2004. Kluwer Academic Publishers, New York

• David Shinar. Traffic safety and Human Behavior. 2007.Elsevier

• Samuel G. Charlton, Thomas G. O’Brien. Handbook od Human Factors Testing and Evaluation

• George A. Peters, Barbara J. Peters. Human Error Causes and Control. 2006. Taylor & Francis Group