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Human Factors Analysis and Classification System (HFACS)
Saving Lives Through Experiences Shared Human Factors Analysis and Classification System (HFACS) A tool to promote a safer fire service
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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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Overview Why HFACS? What is HFACS? Using the tool.
Why - Most mishaps and near misses are the result of human error at several levels. What – A tool developed, tested and used by the U.S. Navy to investigate mishaps. Applying the tool to near-miss reports will have a positive effect on reducing worker injuries and job related fatalities. Using – The tool is easy to apply after an introduction and background reading. Montgomery County Fire & Rescue (MD)
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Opportunities to learn
Why Study Near Misses? 1 Tragic Opportunity to learn 1 Serious Accident 300 Survival Stories Opportunities to learn 15 Major Accidents 300 Near Misses 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. 15,000 Observed Worker Errors H. W. Heinrich, 1930
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Contributing Factors Self reported. Confirmed by interview.
“Human” elements lead list. Findings from 2006 & 2007 have human factors (situational awareness, human error, decision making and communication) leading contributing factors’ list for near miss reports.
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Error Person approach Basic premise: unsafe acts arise primarily from aberrant mental processes 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. Countermeasures: reduce unwanted variability in human behavior. Methods include poster campaigns that appeal to people's sense of fear, writing procedure (or adding to existing ones), 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 organizational processes that give rise to them. Countermeasures: change the conditions under which humans work. Central idea is system defenses. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defenses failed. Reason advocates the System Approach, recognizing that accidents are the result of a chain of error and the Person Approach suppresses communication and admission of error. Reason, James, British Journal of Medicine
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To err is human . . . How It Is Now . . . How It Should Be . . .
You are highly trained You are human and and Humans make mistakes If you did as trained, you would not make mistakes so so Let’s also explore why the system allowed, or failed to accommodate your mistake You weren’t careful enough Punishment for errors results in suppressed reporting of minor mishaps which has been proven to contribute to major incidents. The human factors approach recognizes that humans make mistakes and that those mistakes are usually the culminating effect of multiple factors in the chain of command. 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 Reason states that when holes line up, disaster occurs. The holes represent situations and conditions that allow errors to turn into tragedies. Reason further states that the accident or incident is a function of omissions or actions at all four areas of human performance. 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 Willful disregard for rules & regulations
Lack of skill Lack of education/training Poor decision making misperception Violation Willful disregard for rules & regulations or Ask class for examples of each to ensure they understand the concept of what happens in the Unsafe Acts area.
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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) “Telltale” words/phrases Telltale words/phrases: “Aggressive interior attack” coupled with “on a vacant structure.”
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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 Reason opined that failures at each level eventually line up and lead to disaster. Use definitions from reading to explain “Active Conditions” & “Latent Conditions.” Failed or Absent Defenses Modified from Shappell & Wiegmann, JSSC 1997 Near Miss
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Acts Ask class for opinion of what took place. Keep focus on human element.
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UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors
Decision Skill-Based Unsafe Acts Note Unsafe Acts has two categories: Errors (mistakes) and Violations (willful). Consult reading for definitions of errors and violations. Definitions for each category follow.
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DECISION ERROR UNSAFE ACTS Errors Decision UNSAFE ACTS Errors
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 UNSAFE ACTS Errors Skill-Based UNSAFE ACTS Errors
Violations Decision Errors Perceptual Errors Routine Exceptional SKILL-BASED ERRORS Unsafe Acts Attention Failures Memory Failures Technique Failures
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PERCEPTUAL ERRORS UNSAFE ACTS Errors Perceptual UNSAFE ACTS Errors
Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional PERCEPTUAL ERRORS Unsafe Acts Underestimated critical incident factors Misinterpreted CIRs Visual Illusions
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ROUTINE VIOLATIONS Violations Routine UNSAFE ACTS Violations Routine
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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Substandard Conditions of Operators
PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Individuals Personal Readiness Crew 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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CREW 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 Individuals PRECONDITIONS FOR UNSAFE ACTS Crew Resource Mismanagement CREW RESOURCE MISMANAGEMENT Preconditions for Unsafe Acts Unsafe Acts Failed to communicate Failed to use all resources Failed to recognize task limitations Failed to lead Failed to follow
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PERSONAL READINESS 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 Practices of Individuals 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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Inadequate Supervision Permitted 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
Permitted 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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PERMITTED INAPPROPRIATE
Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Unforeseen Known Permitted Inappropriate Operations UNSAFE SUPERVISION Known Unsafe Supervision Preconditions for Unsafe Acts Acts PERMITTED INAPPROPRIATE OPERATIONS Failed to Adequately Brief Understaffed Permitted Unnecessary Hazard 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 Failed to recognize/id unqualified crew Failed to provide training Failed to correct freelancing
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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 Authorized Unnecessary Hazards Failed to Enforce Rules/Regs/SOPs Authorized unqualified crew to perform tasks
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The Organization’s Role
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ORGANIZATIONAL INFLUENCES Resource Organizational Operational
Climate Resource Management Operational Process ORGANIZATIONAL INFLUENCES Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts
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RESOURCE MANAGEMENT Organizational Climate Resource Management
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 Organizational Climate Resource Management
INFLUENCES Operational Process ORGANIZATIONAL INFLUENCES Organizational Influences OPERATIONAL PROCESS Unsafe Supervision Preconditions for Unsafe Acts Operations Procedures Oversight Unsafe Acts
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QUESTIONS?
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