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Human Factors Analysis and Classification System HFACS www.firefighternearmiss.com A tool to promote a safer fire service.

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Presentation on theme: "Human Factors Analysis and Classification System HFACS www.firefighternearmiss.com A tool to promote a safer fire service."— Presentation transcript:

1 Human Factors Analysis and Classification System HFACS www.firefighternearmiss.com A tool to promote a safer fire service

2 Overview Why HFACS? What is HFACS? Using the tool. www.firefighternearmiss.com

3 (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. Human Factors Analysis and Classification System www.firefighternearmiss.com

4 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. www.firefighternearmiss.com

5 Why Study Near Misses? 1 Serious Accident 15 Major Accidents 300 Near Misses 15,000 Observed Worker Errors 1Tragic Opportunity to learn Opportunity to learn 300 Survival Stories Opportunities to learn www.firefighternearmiss.com

6 Contributing Factors Self reported. Confirmed by interview. Human elements lead list. www.firefighternearmiss.com

7 Error Person Approach 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 peoples 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. www.firefighternearmiss.com

8 To error is human... How It Is Now... You are highly trained and If you did as trained, you would not make mistakes so You werent careful enough so You should be PUNISHED! How It Should Be... Humans make mistakes so Lets also explore why the system allowed, or failed to accommodate your mistake and Lets IMPROVE THE SYSTEM! www.firefighternearmiss.com You are human and

9 Reasons Swiss Cheese Preconditions Unsafe Supervision Org. Influences Unsafe Acts Crew Actions Fatigue Complacency Loss of Situational Awareness Task Allocation Failure to Correct Willful Disregard Ill-defined SOPs Labor Issues Low Morale

10 HFACS Focuses on four areas of human performance Acts Preconditions to Acts Supervision Organizational Influences www.firefighternearmiss.com

11 Acts or Error Lack of skill Lack of education/training Poor decision making misperception Violation Willful disregard for rules & regulations www.firefighternearmiss.com

12 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 www.firefighternearmiss.com

13 Supervision Adequate or inadequate Failure to correct Planned inappropriate ops Effect of freelancing www.firefighternearmiss.com

14 Organizational Influences Most difficult to assess Need to read between the lines Resources Departmental climate SOPs (or lack of) www.firefighternearmiss.com

15 Near Miss Latent Conditions Active Conditions Failed or Absent Defenses Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Modified from Shappell & Wiegmann, JSSC 1997 Reasons Swiss Cheese

16 Acts www.firefighternearmiss.com

17 Unsafe Acts UNSAFE ACTS UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts www.firefighternearmiss.com

18 Violations ExceptionalRoutine 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 www.firefighternearmiss.com

19 Violations ExceptionalRoutin e 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 www.firefighternearmiss.com

20 Violations Exceptiona l Routin e 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 Misread Cues Spatial Disorientation Visual Illusions www.firefighternearmiss.com

21 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 www.firefighternearmiss.com

22 Routine Violations Exceptional UNSAFE ACTS UNSAFE ACTS Errors Perceptua l 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 www.firefighternearmiss.com

23 Preconditions www.firefighternearmiss.com

24 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 www.firefighternearmiss.com

25 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 www.firefighternearmiss.com

26 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 CO poisoning Medical Illness Intoxication www.firefighternearmiss.com

27 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 www.firefighternearmiss.com

28 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 crew Coordination Improper Briefing Before a Mission Inadequate Coordination of Ops www.firefighternearmiss.com

29 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 Inadequate Pre-shift Rest Bottle-to-Brief Rules Self-Medicating Poor Judgement Poor Dietary Practices Overexertion While Off Duty Excessive Voluntary PT www.firefighternearmiss.com

30 The Officers Role www.firefighternearmiss.com

31 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 www.firefighternearmiss.com

32 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 www.firefighternearmiss.com

33 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 www.firefighternearmiss.com

34 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 www.firefighternearmiss.com

35 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 www.firefighternearmiss.com

36 The Organizations Role www.firefighternearmiss.com

37 Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES www.firefighternearmiss.com

38 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 www.firefighternearmiss.com

39 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 www.firefighternearmiss.com

40 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 www.firefighternearmiss.com

41 QUESTIONS? Human Factors Analysis and Classification System www.firefighternearmiss.com


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