Presentation on theme: "Human Factors Analysis and Classification System"— Presentation transcript:
1Human Factors Analysis and Classification System HFACSA tool to promotea safer fire service
2Overview Why HFACS? What is HFACS? Using the tool.
3Human 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.
4Student 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.
5Opportunities to learn Why Study Near Misses?1TragicOpportunity to learn300Survival StoriesOpportunities to learn1 SeriousAccident15 Major AccidentsFocus 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 Misses15,000 Observed Worker Errors
6Contributing Factors Self reported. Confirmed by interview. “Human” elements lead list.
7Error 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 ApproachBasic 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.
8You weren’t careful enough To error is human . . .How It Is Now . . .How It Should Be . . .You are highly trainedYou are humanandandIf you did as trained, you would not make mistakesHumans make mistakessoLet’s also explore why the system allowed, or failed to accommodate your mistakesoYou weren’t careful enoughsoandYou should be PUNISHED!Let’s IMPROVE THE SYSTEM!
9Reason’s “Swiss Cheese” Ill-defined SOP’sLabor IssuesLow MoraleOrg. InfluencesUnsafe SupervisionTask AllocationFailure to CorrectWillful DisregardPreconditionsUnsafe ActsFatigueComplacencyLoss of Situational AwarenessCrew Actions
10HFACS Focuses on four areas of human performance Acts Preconditions to ActsSupervisionOrganizational Influences
11Acts or Error Violation Lack of skill Willful disregard for Lack of education/trainingPoor decision makingmisperceptionViolationWillfuldisregard forrules®ulationsor
12Assesses condition of person or people involved Preconditions to ActsAssesses condition of person or people involvedFocused or distractedHurriedPhysically ill or unfitWrong person for jobCRM usedReadiness
13Supervision Adequate or inadequate Failure to correct Planned inappropriate opsEffect of freelancing
14Organizational Influences Most difficult to assessNeed to “read betweenthe lines”ResourcesDepartmental climateSOPs (or lack of)
18DECISION ERROR www.firefighternearmiss.com UNSAFE ACTS Errors Decision ViolationsDecisionErrorsSkill-BasedErrorsPerceptualErrorsRoutineExceptionalDECISION ERRORUnsafeActsRule-based- Misapplication of a good rule- Application of a bad ruleKnowledge-based- Inaccurate or incompleteknowledge of the problem
21ROUTINE VIOLATIONS www.firefighternearmiss.com Violations Routine UNSAFEACTSViolationsRoutineUNSAFEACTSErrorsDecisionErrorsSkill-BasedErrorsPerceptualErrorsExceptionalROUTINE VIOLATIONSUnsafeActsHabitual departures from rules condoned by management
22EXCEPTIONAL VIOLATIONS UNSAFEACTSViolationsExceptionalUNSAFEACTSErrorsDecisionErrorsSkill-BasedErrorsPerceptualErrorsRoutineExceptionalEXCEPTIONAL VIOLATIONSUnsafeActsIsolated departures from rulesNOT condoned by management
24www.firefighternearmiss.com PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of OperatorsSubstandard Practices of OperatorsPersonal ReadinessInterpersonal Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesPreconditionsforUnsafe ActsUnsafeActs
25Substandard Conditions of Operators PRECONDITIONSFORUNSAFE ACTSAdverse Mental StatesPRECONDITIONSFORUNSAFE ACTSSubstandard Conditions of OperatorsSubstandard Practices of OperatorsAdverse Mental StatesAdverse Physiological StatesPhysical/MentalLimitationsInterpersonal Resource MismanagementPersonal ReadinessADVERSE MENTAL STATEPreconditionsforUnsafe ActsUnsafeActsLoss of Situational AwarenessCircadian dysrhythmiaAlertness (Drowsiness)OverconfidenceComplacencyTask Fixation
26ADVERSE PHYSIOLOGICAL STATES Substandard Conditions of OperatorsSubstandard Practices of OperatorsPRECONDITIONSFORUNSAFE ACTSPersonal ReadinessInterpersonal Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesSubstandard Conditions of OperatorsPRECONDITIONSFORUNSAFE ACTSAdverse Physiological StatesADVERSE PHYSIOLOGICALSTATESPreconditionsforUnsafe ActsUnsafeActsCO poisoningMedical IllnessIntoxication
27PHYSICAL/MENTAL LIMITATIONS Substandard Conditions of OperatorsSubstandard Practices of OperatorsPRECONDITIONSFORUNSAFE ACTSPersonal ReadinessInterpersonal Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesSubstandard Conditions of OperatorsPRECONDITIONSFORUNSAFE ACTSPhysical/MentalLimitationsPHYSICAL/MENTALLIMITATIONSPreconditionsforUnsafe ActsUnsafeActsLack of Sensory InputLimited Reaction TimeIncompatible Physical CapabilitiesIncompatible Intelligence/Aptitude
28INTERPERSONAL RESOURCE MISMANAGEMENT Substandard Conditions of OperatorsSubstandard Practices of OperatorsPRECONDITIONSFORUNSAFE ACTSPersonal ReadinessInterpersonal Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesSubstandard Practices of OperatorsPRECONDITIONSFORUNSAFE ACTSInterpersonal Resource MismanagementINTERPERSONAL RESOURCEMISMANAGEMENTPreconditionsforUnsafe ActsUnsafeActsNot Working as a TeamPoor crew CoordinationImproper Briefing Before a MissionInadequate Coordination of Ops
29PERSONAL READINESS www.firefighternearmiss.com Substandard Conditions of OperatorsSubstandard Practices of OperatorsPRECONDITIONSFORUNSAFE ACTSPersonal ReadinessInterpersonal Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesSubstandard Practices of OperatorsPRECONDITIONSFORUNSAFE ACTSPersonal ReadinessPERSONAL READINESSPreconditionsforUnsafe ActsUnsafeActsReadiness ViolationsInadequate Pre-shift RestBottle-to-Brief RulesSelf-MedicatingPoor JudgementPoor Dietary PracticesOverexertion While Off DutyExcessive “Voluntary” PT
32INADEQUATE SUPERVISION PlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownInadequateSupervisionUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsINADEQUATE SUPERVISIONFailure to Administer Proper TrainingLack of Professional Guidance
33PLANNED INAPPROPRIATE InadequateSupervisionPlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownPlannedInappropriateOperationsUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsPLANNED INAPPROPRIATEOPERATIONSImproper Work TempoPoor Crew Pairing
34FAILED TO CORRECT A KNOWN PROBLEM InadequateSupervisionPlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownFailed toCorrectProblemUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsFAILED TO CORRECT AKNOWN PROBLEMFailure to Correct InappropriateBehaviorFailure to Correct a Safety Hazard
35SUPERVISORY VIOLATIONS InadequateSupervisionPlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownSupervisoryViolationsUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsSUPERVISORY VIOLATIONSNot Adhering to Rules and RegulationsWillful Disregard for Authority bySupervisors