Presentation on theme: "Human Factors Analysis and Classification System (HFACS)"— Presentation transcript:
1Human Factors Analysis and Classification System (HFACS) Saving Lives Through Experiences SharedHuman Factors Analysis and Classification System (HFACS)A tool to promotea saferfire service
2Student 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.
3Overview 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)
4Opportunities to learn Why Study Near Misses?1TragicOpportunity to learn1 SeriousAccident300Survival StoriesOpportunities to learn15 Major Accidents300 Near MissesFocus 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 ErrorsH. W. Heinrich, 1930
5Contributing 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.
6ErrorPerson approachBasic 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 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 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
7To err is human . . . How It Is Now . . . How It Should Be . . . You are highly trainedYou are humanandandHumans make mistakesIf you did as trained, you would not make mistakessosoLet’s also explore why the system allowed, or failed to accommodate your mistakeYou weren’t careful enoughPunishment 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.soandYou should be PUNISHED!Let’s IMPROVE THE SYSTEM!
8Reason’s “Swiss Cheese” Ill-defined SOP’sLabor IssuesLow MoraleOrg. InfluencesUnsafe SupervisionTask AllocationFailure to CorrectWillful DisregardPreconditionsUnsafe ActsFatigueComplacencyLoss of Situational AwarenessReason 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
9HFACS Focuses on four areas of human performance Acts Preconditions to ActsSupervisionOrganizational Influences
10Acts or Error Violation Willful disregard for rules & regulations Lack of skillLack of education/trainingPoor decision makingmisperceptionViolationWillfuldisregard forrules®ulationsorAsk class for examples of each to ensure they understand the concept of what happens in the Unsafe Acts area.
11Assesses condition of person or people involved Preconditions to ActsAssesses condition of person or people involvedFocused or distracted?Hurried?Physically ill or unfit?Wrong person for job?CRM used?Readiness?
12Supervision Adequate or inadequate Failure to correct Planned inappropriate opsEffect of freelancing
13Organizational Influences Most difficult to assessNeed to “read betweenthe lines”ResourcesDepartmental climateSOPs (or lack of)“Telltale” words/phrasesTelltale words/phrases: “Aggressive interior attack” coupled with “on a vacant structure.”
14Reason’s Swiss Cheese Latent Conditions Latent Conditions OrganizationalInfluencesLatent ConditionsUnsafeSupervisionLatent ConditionsPreconditionsforUnsafe ActsLatent ConditionsUnsafeActsActive ConditionsReason opined that failures at each level eventually line up and lead to disaster. Use definitions from reading to explain “Active Conditions” & “Latent Conditions.”Failed orAbsent DefensesModified from Shappell & Wiegmann, JSSC 1997Near Miss
15ActsAsk class for opinion of what took place. Keep focus on human element.
16UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors DecisionSkill-BasedUnsafeActsNote Unsafe Acts has two categories: Errors (mistakes) and Violations (willful). Consult reading for definitions of errors and violations. Definitions for each category follow.
17DECISION ERROR UNSAFE ACTS Errors Decision UNSAFE ACTS Errors ViolationsDecisionErrorsSkill-BasedErrorsPerceptualErrorsRoutineExceptionalDECISION ERRORUnsafeActsRule-based- Misapplication of a good rule- Application of a bad ruleKnowledge-based- Inaccurate or incompleteknowledge of the problem
20ROUTINE VIOLATIONS Violations Routine UNSAFE ACTS Violations Routine ErrorsDecisionErrorsSkill-BasedErrorsPerceptualErrorsExceptionalROUTINE VIOLATIONSUnsafeActsHabitual departures from rules condoned by management
21EXCEPTIONAL VIOLATIONS UNSAFEACTSViolationsExceptionalUNSAFEACTSErrorsDecisionErrorsSkill-BasedErrorsPerceptualErrorsRoutineExceptionalEXCEPTIONAL VIOLATIONSUnsafeActsIsolated departures from rulesNOT condoned by management
23Substandard Conditions of Operators PRECONDITIONSFORUNSAFE ACTSSubstandard Conditions of OperatorsSubstandard Practices of IndividualsPersonal ReadinessCrew Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesPreconditionsforUnsafe ActsUnsafeActs
24Substandard 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
25ADVERSE 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
26PHYSICAL/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
27CREW RESOURCE MISMANAGEMENT Substandard Conditions of OperatorsSubstandard Practices of OperatorsPRECONDITIONSFORUNSAFE ACTSPersonal ReadinessInterpersonal Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesSubstandard Practices of IndividualsPRECONDITIONSFORUNSAFE ACTSCrew Resource MismanagementCREW RESOURCEMISMANAGEMENTPreconditionsforUnsafe ActsUnsafeActsFailed to communicateFailed to use all resourcesFailed to recognize task limitationsFailed to leadFailed to follow
28PERSONAL READINESS Substandard Conditions of Operators Substandard Practices of OperatorsPRECONDITIONSFORUNSAFE ACTSPersonal ReadinessCrew Resource MismanagementAdverse Physiological StatesPhysical/MentalLimitationsAdverse Mental StatesSubstandard Practices of IndividualsPRECONDITIONSFORUNSAFE ACTSPersonal ReadinessPERSONAL READINESSPreconditionsforUnsafe ActsUnsafeActsReadiness ViolationsInadequate Pre-shift RestBottle-to-Brief RulesSelf-MedicatingPoor JudgementPoor Dietary PracticesOverexertion While Off DutyExcessive “Voluntary” PT
30Inadequate Supervision Permitted Inappropriate Operations Failed to CorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownUnsafeSupervisionPreconditionsforUnsafe ActsActs
31INADEQUATE SUPERVISION PermittedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownInadequateSupervisionUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsINADEQUATE SUPERVISIONFailure to Administer Proper TrainingLack of Professional Guidance
33FAILED TO CORRECT A KNOWN PROBLEM InadequateSupervisionPlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownFailed toCorrectProblemUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsFAILED TO CORRECT AKNOWN PROBLEMFailed to recognize/id unqualified crewFailed to provide trainingFailed to correct freelancing
34SUPERVISORY VIOLATIONS InadequateSupervisionPlannedInappropriateOperationsFailed toCorrectProblemSupervisoryViolationsUNSAFESUPERVISIONUnforeseenKnownSupervisoryViolationsUNSAFESUPERVISIONKnownUnsafeSupervisionPreconditionsforUnsafe ActsActsSUPERVISORY VIOLATIONSAuthorized Unnecessary HazardsFailed to Enforce Rules/Regs/SOPsAuthorized unqualified crew to perform tasks