1. Jim Page, 2007 Chapter 12: Human Factors Investigation MINA Handbook

2. Jim Page, 2007 HUMAN FACTORS

3. Jim Page, 2007 Human Error Rates simulated mil emergency Crew reaction to air disaster simple arithmetic general error of omission passive inspection 1.Human vary in stress resistance 2.Failure mode for humans vice machines 3.Expectations and stereotypes 4.Perception - Seeing things in different ways “seeing” out of calibration as “in tolerance” general error of omission for items embedded in procedure general error of commission (misread) upper level of human credibility two-man team (one do): one check; than reverse roles) 1/ 1 1/ 1,000,000 1/ 100,000 1/ 10,000 1/ 1,000 1/ 100 1/ 10

4. Jim Page, 2007 Deliberative Violation Routine Exceptional Criminal Misconduct Intended Action Why was an unsafe act performed Unintended Action Honest Mistake Rule Based Knowledge Based Lapse Memory Failure Skip Attentional Failure Basic Human Error Types SYSTEMPROBLEMSSYSTEMPROBLEMS Supervision Directing Monitoring Selection Knowledge Skills, Abilities Training Initial Recurring Procedure Published Unpublished Hardware Hazard/risk Safety Devices Warning Devices Discipline

5. Jim Page, 2007 Human Performance Factors Physiological Factors - Health/Lifestyle - Fatigue - Drugs, Alcohol Psychological Factors - Proficiency - Situational Awareness - Experience/Recency - Attention, Attitude - Judgment & Decision-making Personality Factors - Emotional State - Behavior - Personality Style Psychosocial Factors - Peer Influences - Personal & Community - Communication Factors - Operational Factors Physical Factors - Visibility - Reach - Strength, Dexterity - Sensory Limitations

6. Jim Page, 2007 Human Error Issues Risk Taking Knowledge and Skill Human Relationships Communication Responsibility, Accountability, and Enforcement Peer Pressure, Ego and Pride Supervision Training

7. Jim Page, 2007 Managing Human Error

8. Jim Page, 2007 Human Factor Issues Stress Fatigue Boring -- Tedious Heights PPE Energy Noise Training Worker Safety Public Safety Environmental Safety Habituation Human Capabilities Stereotypical Behavior Workload Job Security Motivation and Rewards Limited Work Space

9. Jim Page, 2007 Human Factors Systems Model of a Work Environment Organization Philosophy Other Organizations Policies Procedures Selection Continuous Quality Improvement Supervision Planning Organizing Prioritizing Instructing Instruction Feedback Performance Management Team Building Immediate Environment Facilities Weather Design/Configuration Equipment/Tools/Parts Written/Computer Material Tasks Time Pressure On-the-Job Training Worker Knowledge Skills Abilities Other

10. Jim Page, 2007 Human Factors in the Workplace Philosophy Workers do not make errors on purpose There are factors in the work environment that contribute to human error Errors result from a series of related contributing factors Most of these contributing factors result from processes that can be managed

11. Jim Page, 2007 Management Theories, Styles and Safety Hierarchy of Needs Incongruency Expectance and Reward Theory X and Theory Y System 4 The Managerial Grid

12. Jim Page, 2007 The SHEL Model L L H S E S = Software (procedures symbology, etc) H = Hardware (machine) E = Environment L = Liveware The match or mismatch of the blocks (interface) is just as important as the characteristics of the blocks. A mismatch can be source of human error.

13. Jim Page, 2007 The Individual -- “Livewire” L L H S E Physical Factors Characteristics Sensory Limitations Physiological Factors Nutritional, Health Lifestyle, Fatigue Drugs, Alcohol Incapacitation, Illusions Psychological Factors Perceptions, Attention Information Processing Workload Experience Knowledge, Training Planning, Attitudes Mental State, Personality Psychosocial Factors Pressure, Conflict Financial, Family

14. Jim Page, 2007 Livewire - Livewire Interface L L H S E Oral Communications Visual Signs Schedulers, Controllers Team/Crew Interactions Supervision Briefings Task Assignments Co-organization Customers Behavior, Briefing Knowledge of Process, Procedures Worker - Management Personnel - Human Resources Selection, Staffing, Training Policies, Incentives, Seniority Resource allocation, Operating Pressure Supervision Quality Control, Standards Labor Relations Pressures Regulatory Agency Audit, Inspection, Monitoring

15. Jim Page, 2007 Liveware - Machine (Hardware) Interface L L H S E Equipment Switches, Controls Displays Instruments location movement Colors, Markings Illumination Confusion Standardization Workspace Layout, Standardization Communication equipment Eye Reference Position Vis. restrictions Ergonomics Movement Illumination Level Motor Workload Information Displays Alerting and Warnings Operation of Instruments

16. Jim Page, 2007 Human - System -- “Software” Interface L L H S E Written Information Manuals, Checklists, Publications Regulations Maps & Charts Instructions, SOPs, Signage Computers Automation Operator Workload Monitoring Task Task Saturation Situation Awareness Skill Maintenance Utilization Regulatory Requirements Qualifications, Certification Medical Certificate License, Non-compliance Infraction History

17. Jim Page, 2007 Liveware - Environment - Interface L L H S E Immediate work area Heat, Cold Illumination, Glare Acceleration Effective of noise Vibration Air Quality, Humidity Pollution, Fumes Radiation Other Physical Conditions Outside immediate work area Weather, visibility time of day Lighting/glare, other movement, wind Distractions Effects of other on-going activity Other physical conditions

18. Jim Page, 2007 Organizational Culture Shapes our perceptions of safety Determine the relative importance placed on safety Impacts member’s activities regarding safety Senior management plays a big part in setting the tone: –Articulate values –Reinforcement norms

19. Jim Page, 2007 How Do Your Determine Current Culture and the Role of Management? Focus Groups Cross section of organization Questionnaires Attitudes: Safety practices and perceived weaknesses Observations Checklists: on-line behaviors across work cycles Interviews Individual and Group

20. Jim Page, 2007 Looking at Risk Management During an Investigation Two Views: Investigation Management: minimizing risk to the investigators Use of Risk Management: by the mishap organization

21. Jim Page, 2007 Minimizing Risk to the Investigators Investigation management includes hazard identification and risk control at the mishap site. The investigation team leader is responsible for the safety of all team members while overall safety remains with the site manager -- i.e., shop supervisor, police, OSC. AFI 90-901 implements Air Force ORM in “any given situation” - that includes safety functions such as investigation

22. Jim Page, 2007 Basic Principles: The ORM 6-Step Process 1.Identify the Hazards 2.Assess Risks 3.Analyze Risk Control Measures 4.Make Control Decisions 5.Risk Control Implementation 6.Supervise and Review

23. Jim Page, 2007 Minimizing Risk to the Investigators Make a Hazard List –If you are not familiar with the organization’s process, get a supervisor to help you –If you are part of an investigation team, get the team to help you If necessary, do a Hazard Analysis Assess the Risks Analyze the control measures –Use the Safety Order of Precedence Make a decision on the control measures Implement Supervise and Review

24. Jim Page, 2007 Safety Order of Precedence at a Mishap Site Stop the Energy at the Mishap Site Shield Investigators from Energy Remove Investigators from Energy’s Path Use Only Qualified, Trained Investigators –Provide instructions to those augmenting the investigation Protect the Investigators with Safety Equipment, PPE

25. Jim Page, 2007 Absent or Failed Defenses Team/Individual Actions (Unsafe Acts) Absent or Failed Defenses Incident/ Accident Near Miss Investigator climbs external ladder to see top of 25’ tank where a worker fell. Does not want to disturb scene and does not attempt to use fall protection. Investigator climbs with camera in one hand. Investigator slips on ladder rung. Engineering Controls: Source modification Substitution Process change Isolation Administrative Controls: Regulations Instructions Training Quality Assurance Scheduling PPE Investigator falls from a height of 12’ and breaks ankle, loses 5 days of work. Government $1,250 digital camera irreparable damaged.

26. Jim Page, 2007 Absent or Failed Defenses Team/Individual Actions (Unsafe Acts) Absent or Failed Defenses Incident/ Accident Near Miss Entered building with pump engine running subjecting investigation team to high noise levels; Exposed to rotating components; Electrical hazards; Chemical hazards; Life Safety Code hazards. Engineering Controls: Source modification Substitution Process change Isolation Administrative Controls: Regulations Instructions Training Quality Assurance Scheduling PPE Team member’s clothing caught in rotating component, arm severely injured. Possible Class B.

27. Jim Page, 2007 The Organization’s Use of Risk Management Vision: “Create an Air Force in which every leader, airman, and employee is trained and motivated to personally manage risk in all they do, on and off-duty... “ Monitoring: “If the risk control has been well designed, it will favorably change either physical conditions or personnel behavior during the conduct of an operation. The challenge is to determine the extent to which this change is taking place.”

28. Jim Page, 2007 “Every accident, not matter how minor, is a failure of (the) organization”

29. Jim Page, 2007 Man Management Machine Medium The Organization creates risks in meeting work requirements An Organization can minimizing risk and sometimes can eliminate risks The Organization must make risk decisions BOTTOM LINE: An effective Organization needs to identify, assess And control risk Time Mission Investigator Must Understand Conflict in Needs and Goals

30. Jim Page, 2007 General Discussion All our operations and our daily routines involve risk All our operations require decisions that include hazard identification, risk assessment and risk control Effective Risk Management requires a disciplined, organized and logical thought process to make the right decisions Significance of the mission and timeliness of the required action impact the risk decision How much beyond the minimum risk is prudent? Ethically required?

31. Jim Page, 2007 Operational Risk Management A tool for individuals, managers, risk assessment teams and safety personnel to identify hazards and make risk decisions It’s also an investigative tool that can be used to identify the hazards and the risk decisions made by the organization prior to a mishap The Basic Investigator’s Question: How did the organization and the individual identify hazards and then assess and control risk?

32. Jim Page, 2007 The Investigator and Risk Management How much of a problem a hazard presents can’t be determined by the organization until the hazard is converted to a risk. What knowledge of the situation was available and considered before the decision was made? When the hazard is expressed in terms of how likely it is to occur, and how serious the consequences are if it does occur…then the organization can make rational decisions about how to deal with that hazard. Did the organization consider the consequences of its decision?

33. Jim Page, 2007 Risk Management Logic What are the Hazards in the Operation? Yes, Continue No Can this Risk Be Reduced/Minimized? What is the Level of Risk? Is this Level of Risk Acceptable? No Can Risk be Eliminated? Yes, Take Action No Cancel Operation Probability? Severity? Exposure?

34. Jim Page, 2007 Investigating the Use of Operational Risk Management Step 1 - Identify the Hazards - What methodology was used to identify hazards? - Was a hazard ID Tool used? Was it used properly? Was it current? Did the situation change? - Did the system focus on one hazard? - Were the employee(s) involved with the hazard recognition process? - Was human error hazard taken into consideration? Step 2 - Assess the Risks - What risks were assessed? How were they assessed? - What information was available to assist? - Was a Risk Assessment Matrix used? - Were risks prioritized from Greatest to Least?

35. Jim Page, 2007 Investigating the Use of Operational Risk Management Step 3 - Analyze Risk Control Measures - What risk control options were identified? - How were risk control effects determined? - Were risk control measures prioritized? - Were the affected individuals involved with risk control analysis? Step 4 - Make Control Decisions - Who was the control decision maker? - Did the decision maker use available information? - Was the decision made using the best estimate of the overall potential cost? - Was the control decision the best level of risk for the overall mission?

36. Jim Page, 2007 Investigating the Use of Operational Risk Management Step 5 - Implement Risk Controls - Was it clear who would implement the risk control(s)? - Were the people impacted by the control involved with implementing it? Did they know it was a control? Did they understand the control? Did they agree with it? Did they implement it? - Was the control appropriate? - Were the risk controls sustained? Step 6 - Supervise and Review - Were the controls monitored to ensure they remained in place? - Was a feedback mechanism established? - Were ineffective controls corrected? Was the correction timely?

37. Jim Page, 2007 Four Rules of Risk Management 1. Accept no unnecessary risks The key word is “unnecessary.” An unnecessary risk is a risk that does not contribute meaningfully to the operation. Did the organization undertake the activity knowing the hazards and risks as well as appropriate controls? Did it, through omission or commission, accept an unnecessary risk?

38. Jim Page, 2007 Four Rules of Risk Management 2. Make risk decisions at the appropriate level Anyone can make a risk decision; however, the “appropriate level” for an organization’s risk decisions is the one that can allocate the resources and is accountable for the success or failure of the operation. Once that person has established acceptable level of risk, other persons involved in the activity must understand the need to elevate a risk decision when the known residual risk of an activity is at an unnecessary risk level. Given the facts of the mishap, was the risk decision made at the appropriate level?

39. Jim Page, 2007 Four Rules of Risk Management 3. Accept risk when the benefits outweigh the costs There is always risk, and were there is risk, application of a deliberate process to manage risk should minimize the probability of an injury or damage causing event. Risk management requires that the organization making the decision understand the cost and the benefit. That understanding is based on knowledge, experience, and mission requirements. Was a deliberate, risk management process used? What was the decision makers knowledge, experience and mission requirements? Was other knowledge and experience available and used, or not used?

40. Jim Page, 2007 Four Rules of Risk Management 4. Integrate Risk Management into Planning It’s easier to integrate risk management early in the life cycle of any operation (training, operations or combat). When was risk management introduced into the operation? How was risk management introduced into the operation? What resources did the organization offer and use to manage risk? Did the organization provide feedback to the process? Was risk management effective?

41. Jim Page, 2007 Safety Order of Precedence Eliminate The Hazard –The preferred solution – a non-existent hazard cannot cause an accident. Control The Hazard –The most common response –Reduce the severity of the effect or the probability of occurrence of an accident resulting from a hazard.

42. Jim Page, 2007 Safety Order of Precedence Provide Alerts & Warnings –Not an engineering solution –Does nothing to control the hazard –Requires action by an individual Establish Procedural Controls –Does not control the hazard –Remains in place without presence of a hazard. Training in Essential! Accept Residual Risk

43. Jim Page, 2007 What Does This Mean for the Safety Investigator? The investigator needs to answer questions: –How was safety designed in? –What was the analyses that identified the hazards and the design corrective actions? –Was training included for the procedural corrective actions? –Specifically could the design have contributed to the mishap under investigation? –What were the specifications and design criteria that applied when the shop or tool was new? Were they followed and maintained? –Was the acceptable risk level appropriate? –Has the mission or usage changed without a safety assessment? –Were the procedures used appropriate?