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Www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Human Factors Analysis and Classification System (HFACS) A tool to promote.

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Presentation on theme: "Www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System Human Factors Analysis and Classification System (HFACS) A tool to promote."— Presentation transcript:

1 The National Fire Fighter Near-Miss Reporting System Human Factors Analysis and Classification System (HFACS) A tool to promote a safer fire service Saving Lives Through Experiences Shared

2 The National Fire Fighter Near-Miss Reporting System 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.

3 The National Fire Fighter Near-Miss Reporting System Overview Why HFACS? What is HFACS? Using the tool. Montgomery County Fire & Rescue (MD)

4 The National Fire Fighter Near-Miss Reporting System 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 H. W. Heinrich, 1930

5 The National Fire Fighter Near-Miss Reporting System Contributing Factors Self reported. Confirmed by interview. Human elements lead list.

6 The National Fire Fighter Near-Miss Reporting System Error Person approach Basic 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 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 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, James, British Journal of Medicine

7 The National Fire Fighter Near-Miss Reporting System To err is human... How It Is Now...How It Should Be... You are humanYou are highly trained and If you did as trained, you would not make mistakes Humans make mistakes so You werent careful enough Lets also explore why the system allowed, or failed to accommodate your mistake so You should be PUNISHED!Lets IMPROVE THE SYSTEM! and so and

8 The National Fire Fighter Near-Miss Reporting System 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

9 The National Fire Fighter Near-Miss Reporting System HFACS Focuses on four areas of human performance –Acts –Preconditions to Acts –Supervision –Organizational Influences

10 The National Fire Fighter Near-Miss Reporting System Acts Error Lack of skill Lack of education/training Poor decision making misperception Violation Willful disregard for rules & regulations or

11 The National Fire Fighter Near-Miss Reporting System 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?

12 The National Fire Fighter Near-Miss Reporting System Supervision Adequate or inadequate Failure to correct Planned inappropriate ops Effect of freelancing

13 The National Fire Fighter Near-Miss Reporting System Organizational Influences Most difficult to assess Need to read between the lines –Resources –Departmental climate –SOPs (or lack of) –Telltale words/phrases

14 The National Fire Fighter Near-Miss Reporting System 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

15 The National Fire Fighter Near-Miss Reporting System Acts

16 The National Fire Fighter Near-Miss Reporting System Unsafe Acts UNSAFE ACTS UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors Decision Errors Skill-Based Errors

17 The National Fire Fighter Near-Miss Reporting System 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

18 The National Fire Fighter Near-Miss Reporting System 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 Failures Technique Failures

19 The National Fire Fighter Near-Miss Reporting System 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 Underestimated critical incident factors Misinterpreted CIRs Visual Illusions

20 The National Fire Fighter Near-Miss Reporting System 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

21 The National Fire Fighter Near-Miss Reporting System 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

22 The National Fire Fighter Near-Miss Reporting System Preconditions

23 The National Fire Fighter Near-Miss Reporting System Substandard Conditions of Operators Substandard Practices of Individuals PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Preconditions for Unsafe Acts Unsafe Acts

24 The National Fire Fighter Near-Miss Reporting System 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

25 The National Fire Fighter Near-Miss Reporting System 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

26 The National Fire Fighter Near-Miss Reporting System 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

27 The National Fire Fighter Near-Miss Reporting System 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 Individuals PRECONDITIONS FOR UNSAFE ACTS Crew Resource Mismanagement CREW RESOURCE MISMANAGEMENT Failed to communicate Failed to use all resources Failed to recognize task limitations Failed to lead Failed to follow

28 The National Fire Fighter Near-Miss Reporting System Preconditions for Unsafe Acts Unsafe Acts Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Practices of Individuals 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

29 The National Fire Fighter Near-Miss Reporting System The Officers Role

30 The National Fire Fighter Near-Miss Reporting System Inadequate Supervision Permitted Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

31 The National Fire Fighter Near-Miss Reporting System Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Permitted 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

32 The National Fire Fighter Near-Miss Reporting System 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 Permitted Inappropriate Operations UNSAFE SUPERVISION UNSAFE SUPERVISION Known PERMITTED INAPPROPRIATE OPERATIONS Failed to Adequately Brief Understaffed Permitted Unnecessary Hazard Poor Crew Pairing

33 The National Fire Fighter Near-Miss Reporting System 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 Failed to recognize/id unqualified crew Failed to provide training Failed to correct freelancing

34 The National Fire Fighter Near-Miss Reporting System 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 Authorized Unnecessary Hazards Failed to Enforce Rules/Regs/SOPs Authorized unqualified crew to perform tasks

35 The National Fire Fighter Near-Miss Reporting System The Organizations Role

36 The National Fire Fighter Near-Miss Reporting System Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES

37 The National Fire Fighter Near-Miss Reporting System 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

38 The National Fire Fighter Near-Miss Reporting System 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

39 The National Fire Fighter Near-Miss Reporting System 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

40 The National Fire Fighter Near-Miss Reporting System QUESTIONS?


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