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Human Factors Analysis and Classification System
HFACS A tool to promote a safer fire service
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Overview Why HFACS? What is HFACS? Using the tool.
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Human Factors Analysis and Classification System
(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.
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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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Opportunities to learn
Why Study Near Misses? 1 Tragic Opportunity to learn 300 Survival Stories Opportunities to learn 1 Serious Accident 15 Major Accidents Focus on fact that near misses offer 300 more opportunities to improve safety versus one serious accident. Near misses are typically less painful and tragic than serious accidents or fatalities. 300 Near Misses 15,000 Observed Worker Errors
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Contributing Factors Self reported. Confirmed by interview.
“Human” elements lead list.
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Error Person Approach System Approach www.firefighternearmiss.com
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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You weren’t careful enough
To error is human . . . How It Is Now . . . How It Should Be . . . You are highly trained You are human and and If you did as trained, you would not make mistakes Humans make mistakes so Let’s also explore why the system allowed, or failed to accommodate your mistake so You weren’t careful enough so and You should be PUNISHED! Let’s IMPROVE THE SYSTEM!
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Reason’s “Swiss Cheese”
Ill-defined SOP’s Labor Issues Low Morale Org. Influences Unsafe Supervision Task Allocation Failure to Correct Willful Disregard Preconditions Unsafe Acts Fatigue Complacency Loss of Situational Awareness Crew Actions
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HFACS Focuses on four areas of human performance Acts
Preconditions to Acts Supervision Organizational Influences
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Acts or Error Violation Lack of skill Willful disregard for
Lack of education/training Poor decision making misperception Violation Willful disregard for rules & regulations or
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Assesses condition of person or people involved
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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Reason’s Swiss Cheese Latent Conditions Latent Conditions
Organizational Influences Latent Conditions Unsafe Supervision Latent Conditions Preconditions for Unsafe Acts Latent Conditions Unsafe Acts Active Conditions Failed or Absent Defenses Modified from Shappell & Wiegmann, JSSC 1997 Near Miss
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Acts
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Unsafe Acts www.firefighternearmiss.com UNSAFE ACTS Violations Errors
Exceptional Routine Perceptual Errors Decision Skill-Based Unsafe Acts
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DECISION ERROR www.firefighternearmiss.com UNSAFE ACTS Errors Decision
Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional DECISION ERROR Unsafe Acts Rule-based - Misapplication of a good rule - Application of a bad rule Knowledge-based - Inaccurate or incomplete knowledge of the problem
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SKILL-BASED ERRORS www.firefighternearmiss.com UNSAFE ACTS Errors
Violations Decision Errors Perceptual Errors Routine Exceptional SKILL-BASED ERRORS Unsafe Acts Attention Failures Memory Failure
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PERCEPTUAL ERRORS www.firefighternearmiss.com UNSAFE ACTS Errors
Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional PERCEPTUAL ERRORS Unsafe Acts Misjudge Distance Misread Cues Spatial Disorientation Visual Illusions
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ROUTINE VIOLATIONS www.firefighternearmiss.com Violations Routine
UNSAFE ACTS Violations Routine UNSAFE ACTS Errors Decision Errors Skill-Based Errors Perceptual Errors Exceptional ROUTINE VIOLATIONS Unsafe Acts Habitual departures from rules condoned by management
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EXCEPTIONAL VIOLATIONS
UNSAFE ACTS Violations Exceptional UNSAFE ACTS Errors Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional EXCEPTIONAL VIOLATIONS Unsafe Acts Isolated departures from rules NOT condoned by management
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Preconditions
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www.firefighternearmiss.com PRECONDITIONS FOR UNSAFE ACTS
Substandard Conditions of Operators Substandard Practices of Operators Personal Readiness Interpersonal Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Preconditions for Unsafe Acts Unsafe Acts
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Substandard Conditions of Operators
PRECONDITIONS FOR UNSAFE ACTS Adverse Mental States PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Interpersonal Resource Mismanagement Personal Readiness ADVERSE MENTAL STATE Preconditions for Unsafe Acts Unsafe Acts Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation
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ADVERSE PHYSIOLOGICAL STATES
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 Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States ADVERSE PHYSIOLOGICAL STATES Preconditions for Unsafe Acts Unsafe Acts CO poisoning Medical Illness Intoxication
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PHYSICAL/MENTAL LIMITATIONS
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 Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Physical/ Mental Limitations PHYSICAL/MENTAL LIMITATIONS Preconditions for Unsafe Acts Unsafe Acts Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude
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INTERPERSONAL RESOURCE MISMANAGEMENT
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 ACTS Interpersonal Resource Mismanagement INTERPERSONAL RESOURCE MISMANAGEMENT Preconditions for Unsafe Acts Unsafe Acts Not Working as a Team Poor crew Coordination Improper Briefing Before a Mission Inadequate Coordination of Ops
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PERSONAL READINESS www.firefighternearmiss.com
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 ACTS Personal Readiness PERSONAL READINESS Preconditions for Unsafe Acts Unsafe Acts Readiness Violations Inadequate Pre-shift Rest Bottle-to-Brief Rules Self-Medicating Poor Judgement Poor Dietary Practices Overexertion While Off Duty Excessive “Voluntary” PT
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The Officer’s Role
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www.firefighternearmiss.com Inadequate Supervision Planned
Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Unforeseen Known Unsafe Supervision Preconditions for Unsafe Acts Acts
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INADEQUATE SUPERVISION
Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision UNSAFE SUPERVISION Known Unsafe Supervision Preconditions for Unsafe Acts Acts INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance
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PLANNED INAPPROPRIATE
Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Unforeseen Known Planned Inappropriate Operations UNSAFE SUPERVISION Known Unsafe Supervision Preconditions for Unsafe Acts Acts PLANNED INAPPROPRIATE OPERATIONS Improper Work Tempo Poor Crew Pairing
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FAILED TO CORRECT A KNOWN PROBLEM
Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Unforeseen Known Failed to Correct Problem UNSAFE SUPERVISION Known Unsafe Supervision Preconditions for Unsafe Acts Acts FAILED TO CORRECT A KNOWN PROBLEM Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard
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SUPERVISORY VIOLATIONS
Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Unforeseen Known Supervisory Violations UNSAFE SUPERVISION Known Unsafe Supervision Preconditions for Unsafe Acts Acts 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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www.firefighternearmiss.com ORGANIZATIONAL INFLUENCES Resource
Climate Resource Management Operational Process ORGANIZATIONAL INFLUENCES Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts
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RESOURCE MANAGEMENT www.firefighternearmiss.com Organizational Climate
Operational Process ORGANIZATIONAL INFLUENCES Resource Management ORGANIZATIONAL INFLUENCES Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Acts RESOURCE MANAGEMENT Human Monetary Equipment/Facility
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ORGANIZATIONAL CLIMATE
Resource Management Operational Process ORGANIZATIONAL INFLUENCES Organizational Climate ORGANIZATIONAL INFLUENCES Organizational Influences ORGANIZATIONAL CLIMATE Unsafe Supervision Preconditions for Unsafe Acts Structure Policies Culture Unsafe Acts
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OPERATIONAL PROCESS www.firefighternearmiss.com Organizational Climate
Resource Management Operational Process ORGANIZATIONAL INFLUENCES Operational Process ORGANIZATIONAL INFLUENCES Organizational Influences OPERATIONAL PROCESS Unsafe Supervision Preconditions for Unsafe Acts Operations Procedures Oversight Unsafe Acts
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Human Factors Analysis and Classification System
QUESTIONS?
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