human factors analysis and classification system hfacs a tool to promote a safer fire service
TRANSCRIPT
Human Factors Analysis and Classification System
HFACS
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A tool to promotea safer fire service
Overview
Why HFACS?
What is HFACS?
Using the tool.
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(HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing
the human causes of aviation accidents.
Human Factors Analysis and Classification System
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Student Performance Objective
Given an introduction to the Human Factors Analysis and Classification System (HFACS), students/users will apply the tool to various near-miss reports to gain a greater understanding of the role human factors plays in near-misses and mishaps.
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Why Study Near Misses?
1 SeriousAccident
15 Major Accidents
300 Near Misses
15,000 Observed Worker Errors
11
TragicTragic
Opportunity Opportunity to learnto learn
300300
Survival Survival StoriesStories
Opportunities Opportunities to learnto learn
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Contributing Factors
Self reported. Confirmed by interview. “Human” elements lead list.
0
100
200
300
400
500
600
86 86 121
186
4
432
182
45
9
448
319
112 131
42
526
112 53 32 73
183
25 91
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Error
Person Approach Basic Premise: unsafe acts arise primarily from aberrant mental process such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.
Focuses on the unsafe acts, errors, and procedural violations of people
at the sharp end: firefighters, engineers, company officers, paramedics, etc.
Counter measures: reduce unwanted variability in human behavior.
Methods include poster campaigns that appeal to people’s sense of fear, writing procedure (or adding to existing one), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming.
System Approach Basic Premise: humans are fallible and errors are to be expected, even in the best organizations.
Errors seen as consequences rather than causes, origins in “upstream” systemic factors. These include recurrent error traps in the workplace and the organization processes that give rise to them.
Counter measures: change the conditions under which humans work. Central Idea is system defenses. All hazardous technologies posses barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defenses failed.
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To error is human . . .
How It Is Now . . .You are highly trained
and
If you did as trained, you would not make mistakes
so
You weren’t careful enoughso
You should be PUNISHED!
How It Should Be . . .
Humans make mistakes so
Let’s also explore why the system allowed, or failed to accommodate your mistake
and
Let’s IMPROVE THE SYSTEM!
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You are human
and
Reason’s “Swiss Cheese”
Preconditions
Unsafe Supervision
Org. Influences
Unsafe Acts
Crew Actions
Fatigue
Complacency
Loss of Situational Awareness
Task Allocation
Failure to Correct
Willful Disregard
Ill-defined SOP’s
Labor Issues
Low Morale
HFACS
Focuses on four areas of human performance Acts Preconditions to Acts Supervision Organizational
Influences
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Acts
or
Error
Lack of skill
Lack of education/training
Poor decision making
misperception
Violation
Willfuldisregard for
rules
&
regulations
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Preconditions to Acts
Assesses condition of person or people involved
Focused or distracted Hurried Physically ill or unfit Wrong person for job CRM used Readiness
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Supervision
Adequate or inadequate
Failure to correct Planned
inappropriate ops Effect of
freelancing
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Organizational Influences
Most difficult to assess Need to “read between
the lines” Resources Departmental climate SOPs (or lack of)
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Near MissNear Miss
Latent Conditions
Latent Conditions
Latent Conditions
Active Conditions
Failed orAbsent Defenses
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Modified from Shappell & Wiegmann, JSSC 1997
Reason’s Swiss Cheese
Acts
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Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ViolationsErrorsErrors
Exceptional
RoutinePerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe Acts
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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
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Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
Skill-BasedErrors
SKILL-BASEDERRORS
Attention Failures Memory Failure
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Violations
Exceptional
Routine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
PERCEPTUALERRORS
Misjudge Distance Misread Cues Spatial Disorientation Visual Illusions
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Exceptional
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ROUTINE VIOLATIONSHabitual departures
from rules condoned by management
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Routine
Violations
Exceptional
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
Perceptual
Errors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
Exceptional
Violations
Exceptional
UNSAFEACTS
UNSAFEACTS
EXCEPTIONAL VIOLATIONS Isolated departures from rules NOT condoned by management
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Preconditions
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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
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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
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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
CO poisoning Medical Illness Intoxication
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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
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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 crew Coordination Improper Briefing Before a Mission Inadequate Coordination of Ops
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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
Inadequate Pre-shift Rest
Bottle-to-Brief Rules Self-Medicating
Poor Judgement Poor Dietary Practices Overexertion While Off
Duty Excessive “Voluntary”
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The Officer’s Role
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InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
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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
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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
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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
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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
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The Organization’s Role
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OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
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OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
ResourceManagement
ResourceManagement
ORGANIZATIONALINFLUENCES
RESOURCE MANAGEMENT Human Monetary Equipment/Facility
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OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
OrganizationalClimate
ORGANIZATIONALINFLUENCES
ORGANIZATIONALCLIMATE Structure Policies Culture
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OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
OperationalProcess
ORGANIZATIONALINFLUENCES
OPERATIONALPROCESS Operations Procedures Oversight
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QUESTIONS?
Human Factors Analysis and Classification System
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