Presentation on theme: "Human Factors Analysis and Classification System"— Presentation transcript:
1 Human Factors Analysis and Classification System HFACSA tool to promotea safer fire service
2 Overview Why HFACS? What is HFACS? Using the tool.
3 Human 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.
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.
5 Opportunities 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
6 Contributing Factors Self reported. Confirmed by interview. “Human” elements lead list.
7 Error 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.
8 You 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!
9 Reason’s “Swiss Cheese” Ill-defined SOP’sLabor IssuesLow MoraleOrg. InfluencesUnsafe SupervisionTask AllocationFailure to CorrectWillful DisregardPreconditionsUnsafe ActsFatigueComplacencyLoss of Situational AwarenessCrew Actions
10 HFACS Focuses on four areas of human performance Acts Preconditions to ActsSupervisionOrganizational Influences
11 Acts or Error Violation Lack of skill Willful disregard for Lack of education/trainingPoor decision makingmisperceptionViolationWillfuldisregard forrules®ulationsor
12 Assesses condition of person or people involved Preconditions to ActsAssesses condition of person or people involvedFocused or distractedHurriedPhysically ill or unfitWrong person for jobCRM usedReadiness
13 Supervision Adequate or inadequate Failure to correct Planned inappropriate opsEffect of freelancing
14 Organizational Influences Most difficult to assessNeed to “read betweenthe lines”ResourcesDepartmental climateSOPs (or lack of)
18 DECISION 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
24 www.firefighternearmiss.com PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of OperatorsSubstandard Practices of OperatorsPersonal ReadinessInterpersonal Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesPreconditionsforUnsafe ActsUnsafeActs
25 Substandard 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
26 ADVERSE 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
27 PHYSICAL/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
28 INTERPERSONAL 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
29 PERSONAL 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
32 INADEQUATE SUPERVISION PlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownInadequateSupervisionUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsINADEQUATE SUPERVISIONFailure to Administer Proper TrainingLack of Professional Guidance
34 FAILED TO CORRECT A KNOWN PROBLEM InadequateSupervisionPlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownFailed toCorrectProblemUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsFAILED TO CORRECT AKNOWN PROBLEMFailure to Correct InappropriateBehaviorFailure to Correct a Safety Hazard
35 SUPERVISORY VIOLATIONS InadequateSupervisionPlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownSupervisoryViolationsUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsSUPERVISORY VIOLATIONSNot Adhering to Rules and RegulationsWillful Disregard for Authority bySupervisors
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