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

3. Latent Conditions  Budget cuts  Excess workload Latent Conditions  Deficient training program  Improper supervision Latent Conditions  Poor training  Mental Fatigue Active Conditions  Failed to ensure surface could hold backhoe  Loss of situational awareness Failed or Absent Defenses Organizational Factors Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Accident & Injury  Sunk Backhoe into mud Active versus Latent Failures (Reason, 1990)

4. Unsafe Acts UNSAFE ACTS UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors Decision Errors Skill-Based Errors

5. Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors UNSAFE ACTS UNSAFE ACTS Errors Decision Errors DECISION ERROR  Rule-based Decisions - If X, then do Y - Highly Procedural  Choice Decisions - Knowledge-based  Structured Decisions - Problem solving Unsafe Acts

6. Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors UNSAFE ACTS UNSAFE ACTS Errors Skill-Based Errors SKILL-BASED ERRORS  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

7. Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors PERCEPTUAL ERRORS  Misjudge Distance, speed, weight, etc.  Loss of situational awareness  Visual Illusions Unsafe Acts

8. Unsafe Acts Exceptional Violations Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Violations Routine UNSAFE ACTS UNSAFE ACTS ROUTINE (INFRACTIONS) (Habitual departures from rules condoned by management) ä 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 ä Failed to Adhere to Briefed Requirements ä Not Current/Qualified for Equipment ä Improper Procedure

9. Routine Violations Exceptional UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Exceptional Violations Exceptional UNSAFE ACTS UNSAFE ACTS EXCEPTIONAL (Isolated departures from the rules not condoned by management) ä Violated Manuals/Policies/SOPs - Performed Unauthorized Operation - Horseplay with Equipment - Failed to Ensure Equipment was Operational - Allowed Unauthorized Operator - Ignored Equipment Malfunction ä Accepted Unnecessary Risk ä Not Current/Qualified for Equipment ä Exceeded Limits of Equipment Unsafe Acts

10. Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Preconditions for Unsafe Acts Unsafe Acts

11. Preconditions for Unsafe Acts Unsafe Acts Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Mental States ADVERSE MENTAL STATE  Loss of Situational Awareness  Circadian dysrhythmia  Alertness (Drowsiness)  Overconfidence  Complacency  Task Fixation

12. Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States ADVERSE PHYSIOLOGICAL STATES  Hypothermia  Motion Sickness  Fatigue  Medical Illness  Intoxication Preconditions for Unsafe Acts Unsafe Acts

13. Preconditions for Unsafe Acts Unsafe Acts Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Preconditions for Unsafe Acts Unsafe Acts Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Physical/ Mental Limitations PHYSICAL/MENTAL LIMITATIONS  Lack of Sensory Input  Limited Reaction Time  Incompatible Physical Capabilities  Incompatible Intelligence/Aptitude

14. PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Interpersonal Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Conditions of Operators Substandard Practices of Operators Preconditions for Unsafe Acts Unsafe Acts CREW RESOURCE MISMANAGEMENT  Not Working as a Team  Poor Coordination/Communication  Improper or No Tailgate Briefing  Inadequate Coordination of Work Preconditions for Unsafe Acts Unsafe Acts Substandard Practices of Operators

15. Preconditions for Unsafe Acts Unsafe Acts Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Interpersonal Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ATS Personal Readiness PERSONAL READINESS Readiness Problems  Inadequate Rest  Excess Alcohol Consumption  Self-Medicating Poor Judgement  Poor Dietary Practices  Overexertion While Off Duty  Bad Habits Preconditions for Unsafe Acts Unsafe Acts

16. Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

17. UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Inadequate Supervision INADEQUATE SUPERVISION  Failure to Administer Proper Training  Lack of Professional Guidance Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

18. UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Planned Inappropriate Operations PLANNED INAPPROPRIATE OPERATIONS  Risk without Benefit  No Risk Assessment  Improper Work Tempo  Poor Crew Pairing Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

19. Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Failed to Correct Problem UNSAFE SUPERVISION UNSAFE SUPERVISION FAILED TO CORRECT A KNOWN PROBLEM  Failure to Correct Inappropriate Behavior  Failure to Correct a Safety Hazard  Failure to Enforce Safety Rules Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

20. Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION SUPERVISORY VIOLATIONS  Not Adhering to Rules and Regulations  Willful Disregard for Authority by Supervisors  Failure to Conduct Risk Assessment Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

21. Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES

22. Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES Resource Management Resource Management ORGANIZATIONAL INFLUENCES RESOURCE MANAGEMENT  Human  Budget  Equipment/Facility

23. Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES Organizational Climate ORGANIZATIONAL INFLUENCES ORGANIZATIONAL CLIMATE  Structure  Policies  Culture

24. Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES Operational Process ORGANIZATIONAL INFLUENCES OPERATIONAL PROCESS  Operations  Procedures  Oversight

25. Errors Perceptual Errors Skill-Based Errors UNSAFE ACTS Errors Decision Errors Exceptional Routine Violations Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Personal Readiness Interpersonal Resource Mismanagement Substandard Practices of Operators Resource Management Organizational Climate Organizational Process ORGANIZATIONAL INFLUENCES

26. “Whenever we talk about a worker who has been killed in an accident, we should all keep one thing in mind. They...made a judgment. They believed in it so strongly that they knowingly bet their life on it. That their judgment was faulty is a tragedy,… Every instructor, supervisor, and contemporary who ever spoke to them had the opportunity to influence their judgement, so a little bit of all of us goes with every worker we lose.” --Anonymous