Human Factors Theory - Grant Safety Solutions
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Human Factors Theory Update 1 July 2014 1 This can only happen with the human element present – The question is why ???? 34 2 “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997 It is not surprising then, that human error has been implicated in 60-80% of accidents in aviation and other complex systems. In fact, while accidents solely attributable to environmental and mechanical factors have been greatly reduced over the last several years, those attributable to human error continue to plague organizations. 4 Why Investigate the Human Factor • Leading cause of accidents. • DA Pam 385-40 Army Accident Investigation and Reporting – Materiel Factors – Environmental Factors – Human Factors System Inadequacies (figure 2-1) • • • • • Support Standards Training Leader Individual People Make Mistakes! 5 Human Factors: A Brief History • Human factors is a discipline that has grown over the past 120 years. • Early Safety Philosophy • Heinricks Theory • The people had a voice – Union • Accident Investigation required an in depth study 6 What are Human Factors • Fatigue, Body Rhythms and Sleep • Fitness and Performance (Age) • Vision and Visual Illusions • Motivation and Leadership • Communications, Language and Speech • Attitudes and Persuasion • Training and Training Devices • Documentation • Displays and Controls • Space and Layout • Education and Application 7 Where do we usually look to prevent accidents? Unsafe Acts 8 Where should we look to prevent accidents? Operating Environment Unsafe Acts 9 10 A HUMAN FACTORS APPROACH TO ACCIDENT ANALYSIS AND PREVENTION Scott Shappell, Ph.D. Civil Aeromedical Institute Douglas Wiegmann, Ph.D. 12 University of Illinois Wiegmann-Shappell Human Factors Analysis And Classification System (HFACS) OPNAV 3750.6R (Appendix O) Naval Safety Center 375 A Street Norfolk VA 23511-4399 (757) 444-3520 13 14 ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Process UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Planned Inappropriate Operations Inadequate Supervision Failure to Correct Problem Supervisory Violations PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Crew Resource Mismanagement Personal Readiness UNSAFE ACTS Errors Decision Errors Skill-Based Errors Violations Perceptual Errors Routine Exceptional 15 UNSAFE ACTS 80% Violations Errors Skill-based Errors Decision Errors Perceptual Errors Routine Exceptional Unsafe Acts 16 UNSAFE ACTS Violations Errors Skill-Based Decision Errors Unsafe Acts Decision Error Perceptual Errors Routine Exceptional SKILL-BASED ERROR Attention Failures - Breakdown in visual scan - Inadvertent operation of control - Failure to see and avoid Memory Failure - Omitted item in checklist - Omitted step in procedure Execution Failures - over/under reacting/controlling - 5 Points of Performance/PLF 17 UNSAFE ACTS Violations Errors Skill-based Errors Unsafe Acts Skill-Based Decision Errors Perceptual Errors Routine Exceptional DECISION ERRORS Rule-based Decisions - If X, then do Y - Highly Procedural Choice Decisions - Knowledge-based Ill-Structured Decisions - Problem solving 18 UNSAFE ACTS Violations Errors Skill-Based Errors Unsafe Acts Decision Error Perceptual Errors Routine Exceptional PERCEPTUAL ERRORS Misjudge Distance, Altitude, Airspeed, Groundspeed, Azimuth Spatial Disorientation Visual Illusions 19 UNSAFE ACTS Violations Errors Skill-Based Errors Decision Errors Perceptual Errors Routine Exceptional ROUTINE (INFRACTIONS) (Habitual departures from rules condoned by management) Unsafe Acts Violation of Orders/Regulations/SOP - Failed to Inspect Vehicle after Caution Light - Violated Squadron SOP Restricting Flight Below 500’ - Failed to Comply w/-10 load plan or warnings - Conducted Maintenance Mission with PAX - Elected to File VFR in Marginal Weather Conditions - Took Red-Xed Vehicle without Dispatch - Inadequate Brief and Limits on Mission - TC Knowingly Accepted Non-Current Crew Failed to Adhere to Brief Not Current/Qualified for Mission/No Driver’s License Improper Procedure 20 UNSAFE ACTS Violations Errors Skill-Based Errors Decision Errors Perceptual Errors Routine Exceptional EXCEPTIONAL (Isolated departures from the rules not condoned by management) Unsafe Acts Violated Orders/Regulations/SOP - Performed Unauthorized Acrobatic Maneuver - Speeding in Vehicle - Failed to Complete Performance Computations for Flight - Improper Takeoff Technique - Failed to Obtain Valid Weather Brief Accepted Unnecessary Hazard Not Current/Qualified for Mission Exceeded Limits of Aircraft/Vehicle 21 22 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Management Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Preconditions for Unsafe Acts Unsafe Acts 23 PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States Unsafe Acts Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States 80% Physical/ Mental Limitations Crew Resource Management Non-Supervisory Tolerance of Unsafe Acts Dig Deeper Personal Readiness Preconditions for Unsafe Acts Unsafe Acts ADVERSE MENTAL STATE Loss of Situational Awareness Circadian dysrhythmia - Sleep Alertness (Drowsiness) Overconfidence Complacency Task Fixation 24 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Management Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Preconditions for Unsafe Acts Unsafe Acts ADVERSE PHYSIOLOGICAL STATES Medication Hypoxia Motion Sickness Medical Illness Intoxication 25 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Management Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Preconditions for Unsafe Acts PHYSICAL/MENTAL LIMITATIONS Unsafe Acts Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude 26 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Management Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Preconditions for Unsafe Acts Unsafe Acts CREW RESOURCE MANAGEMENT Not Working as a Team Poor Crew Coordination Improper Briefing Before a Mission Inadequate Coordination of Mission Big Problem in Aviation Need Good Communication Skills 27 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Unsafe Acts Adverse Physiological States Physical/ Mental Limitations Supervisory Crew Resource Management Crew Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Rank Gradient SUPERVISORY 28 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Unsafe Acts Adverse Physiological States Physical/ Mental Limitations Supervisory Crew Resource Management Crew Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Rank Gradient CREW 1972 Florida Everglades crash 20 cent light bulb 29 Eastern Airlines Flight 401 Crashed Florida Everglades Lockheed L-1011 (101 Deaths) 30 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Unsafe Acts Adverse Physiological States Physical/ Mental Limitations Supervisory Crew Resource Management Crew Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Rank Gradient RANK GRADIENT Washington, DC Jan 1982 Pilot failed to listen to Copilot Crash into the Potomac River 31 Air Florida Flight 90 Crashed into the Potomac River Boeing 737-300 (74 Deaths) 32 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Management Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Preconditions for Unsafe Acts Unsafe Acts NON-SUPERVISORY TOLERANCE Failure to report incidents of misconduct Toleration of unsafe acts and behaviors 33 PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Management Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Preconditions for Unsafe Acts Unsafe Acts PERSONAL READINESS Readiness Violations Crew Rest Requirements Bottle-to-Brief Rules Self-Medicating Poor Judgement Poor Dietary Practices Overexertion While Off Duty Excessive “Voluntary” PT 34 UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Inadequate Supervision Planned Inappropriate Operations Failure to Correct Problem Supervisory Violations Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts While empowering individuals to make decisions and function independently is certainly essential, this does not divorce the Leader from accountability 35 UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Inadequate Supervision Planned Inappropriate Operations Failure to Correct Problem Supervisory Violations Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts UNRECOGNIZED HAZARDOUS OPERATIONS Loss of Supervisory Situational Awareness “Don’t Know What You Don’t Know” Hazards go unseen/unrecognized Supervisor is over-tasked / untrained No mentorship / role model 36 UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Inadequate Supervision Planned Inappropriate Operations Failure to Correct Problem Supervisory Violations Unsafe Supervision Preconditions for Unsafe Acts INADEQUATE DOCUMENTAION/ PROCEDURES Unsafe Acts Failure of standards No Standards Recognized “after the fact” 37 UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Inadequate Supervision Planned Inappropriate Operations Failure to Correct Problem Supervisory Violations Unsafe Supervision Preconditions for Unsafe Acts INADEQUATE SUPERVISION Unsafe Acts Failure to Administer Proper Training Lack of Professional Guidance/Mentor 38 UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Inadequate Supervision Planned Inappropriate Operations Failure to Correct Problem Supervisory Violations Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts PLANNED INAPPROPRIATE OPERATIONS Mission Risk without Benefit Improper Work Tempo Poor Crew Pairing Poor Planning by Leaders 39 UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Inadequate Supervision Planned Inappropriate Operations Failure to Correct Problem Supervisory Violations Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts FAILED TO CORRECT A KNOWN PROBLEM Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard 40 UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Inadequate Supervision Planned Inappropriate Operations Failure to Correct Problem Supervisory Violations Unsafe Supervision Preconditions for Unsafe Acts SUPERVISORY VIOLATIONS Unsafe Acts Not Adhering to Rules and Regulations Willful Disregard for Authority by Supervisors 41 ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Operational Process Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts 42 ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences Operational Process RESOURCE MANAGEMENT Human Monetary Equipment/Facility Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts 43 ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Operational Process ORGANIZATIONAL CLIMATE Organizational Influences Structure Policies Culture Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts 44 ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences Operational Process OPERATIONAL PROCESS Unsafe Supervision Operations Procedures Oversight Preconditions for Unsafe Acts Unsafe Acts 45 ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Process UNSAFE SUPERVISION Unforeseen Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Known Planned Inappropriate Operations Inadequate Supervision Failure to Correct Problem Supervisory Violations PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Crew Resource Mismanagement Personal Readiness UNSAFE ACTS Errors Decision Errors Skill-Based Errors Violations Perceptual Errors Routine Exceptional 46 SUMMARY HFACS provides: A system to record and correlate causes of human failure for future prevention controls. Over time will provides information that can be used for accident prevention ! ? Why holes exist ? What we can do to prevent holes ? Risk Management ! ? How can HFACS be used to prevent accidents before they occur? 47 A SOLDIER’S FAILURE MAY NOT BE DUE TO HIS OWN ACTIONS. Organizational Influences Driver’s Training Program Failure. Unsafe Supervisory Practices Failed to Correct a Known Problem. Inadequate NCO Supervision. Inadequate Maintenance Supervision. Preconditions for Unsafe Acts Fatigue. Inexperience. Support Failure. Human factors at every level of the Department of the Army can influence mission outcomes for the individual soldier. When failures occur at the different levels they open windows of opportunity for the soldier to fail. Unsafe Soldier Actions Failure to Follow Procedure. Speeding Violation. Driving Blind. Driving Skill Error. Accident 48 Putting It All Together Special Observation Present and Contributing Unsafe Inputs to the Organization & an Unsafe Operating Environment Organizational Factors Unsafe Supervision Present but not Contributing Preconditions for Unsafe Acts Unsafe Acts 49 Wiegmann and Shappell, 1999 Mission Success Safe Inputs to the Organization & a Safe Operating Environment Safe Organizational Factors Safe Supervision Plug the holes & prevent the accidents! Wiegmann and Shappell, 1999 Preconditions for Safe Acts Safe Acts 50 When we get it right! 51 When we get it right? 52 When we get it right? 53 Conclusion It is our belief that the Humans Factors Analysis and Classification System (HFACS) framework bridges the gap between theory and practice by providing investigators with a comprehensive, user friendly tool for identifying and classifying the human causes or aviation accidents. Shappell and Wiegmann – February 2000 54
