1. Shappell and Wiegmann, 1997 A FAILURE ANALYSIS AND CLASSIFICATION SYSTEM

2. Shappell and Wiegmann, 1997 Accident & Injury Latent Conditions Active Conditions Failed or Absent Defenses Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

3. Shappell and Wiegmann, 1997 Unsafe Acts UNSAFE ACTS UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors Decision Errors Skill-Based Errors

4. Shappell and Wiegmann, 1997 Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Decision Errors DECISION ERROR   Rule-based - Misapplication of a good rule - Application of a bad rule   Knowledge-based - Inaccurate or incomplete knowledge of the problem

5. Shappell and Wiegmann, 1997 Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Skill-Based Errors SKILL-BASED ERRORS   Attention Failures   Memory Failure

6. Shappell and Wiegmann, 1997 Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors PERCEPTUAL ERRORS   Misjudge Distance, Altitude, Airspeed   Spatial Disorientation   Visual Illusions

7. Shappell and Wiegmann, 1997 Exceptional Violations Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts Violations Routine UNSAFE ACTS UNSAFE ACTS ROUTINE VIOLATIONS   Habitual departures from rules condoned by management

8. Shappell and Wiegmann, 1997 Routine Violations Exceptional UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts Exceptional Violations Exceptional UNSAFE ACTS UNSAFE ACTS EXCEPTIONAL VIOLATIONS   Isolated departures from rules NOT condoned by management

9. Shappell and Wiegmann, 1997

10. 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 Preconditions for Unsafe Acts Unsafe Acts

11. Shappell and Wiegmann, 1997 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 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. Shappell and Wiegmann, 1997 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 Preconditions for Unsafe Acts Unsafe Acts Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States ADVERSE PHYSIOLOGICAL STATES   Hypoxia   Motion Sickness   Medical Illness   Intoxication

13. Shappell and Wiegmann, 1997 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 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. Shappell and Wiegmann, 1997 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 ACTS Interpersonal Resource Mismanagement INTERPERSONAL RESOURCE MISMANAGEMENT   Not Working as a Team   Poor Aircrew Coordination   Improper Briefing Before a Mission   Inadequate Coordination of Flight

15. Shappell and Wiegmann, 1997 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 ACTS Personal Readiness PERSONAL READINESS Readiness Violations   Crew Rest Requirements   Bottle-to-Brief Rules   Self-Medicating Poor Judgement   Poor Dietary Practices   Overexertion While Off Duty   Excessive “Voluntary” PT

16. Shappell and Wiegmann, 1997

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

18. Shappell and Wiegmann, 1997 Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

19. Shappell and Wiegmann, 1997 Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision UNSAFE SUPERVISION UNSAFE SUPERVISION Known INADEQUATE SUPERVISION   Failure to Administer Proper Training   Lack of Professional Guidance

20. Shappell and Wiegmann, 1997 Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Planned Inappropriate Operations UNSAFE SUPERVISION UNSAFE SUPERVISION Known PLANNED INAPPROPRIATE OPERATIONS   Improper Work Tempo   Poor Crew Pairing

21. Shappell and Wiegmann, 1997 Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Failed to Correct Problem UNSAFE SUPERVISION UNSAFE SUPERVISION Known FAILED TO CORRECT A KNOWN PROBLEM   Failure to Correct Inappropriate Behavior   Failure to Correct a Safety Hazard

22. Shappell and Wiegmann, 1997 Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Known SUPERVISORY VIOLATIONS   Not Adhering to Rules and Regulations   Willful Disregard for Authority by Supervisors

23. Shappell and Wiegmann, 1997

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

25. Shappell and Wiegmann, 1997 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   Monetary   Equipment/Facility

26. Shappell and Wiegmann, 1997 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

27. Shappell and Wiegmann, 1997 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