Human Factors Analysis and Classification System HFACS A tool to promote a safer fire service.

Human Factors Analysis and Classification System

HFACS

www.firefighternearmiss.com

A tool to promotea safer fire service

Overview

Why HFACS?

What is HFACS?

Using the tool.


(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.



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.


Why Study Near Misses?

1 SeriousAccident

15 Major Accidents

300 Near Misses

15,000 Observed Worker Errors

11

TragicTragic

Opportunity Opportunity to learnto learn

300300

Survival Survival StoriesStories

Opportunities Opportunities to learnto learn


Contributing Factors

Self reported. Confirmed by interview. “Human” elements lead list.

0

100

200

300

400

500

600

86 86 121

186

4

432

182

45

9

448

319

112 131

42

526

112 53 32 73

183

25 91


Error

Person Approach 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 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 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.


To error is human . . .

How It Is Now . . .You are highly trained

and

If you did as trained, you would not make mistakes

so

You weren’t careful enoughso

You should be PUNISHED!

How It Should Be . . .

Humans make mistakes so

Let’s also explore why the system allowed, or failed to accommodate your mistake

and

Let’s IMPROVE THE SYSTEM!


You are human

and

Reason’s “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 SOP’s

Labor Issues

Low Morale

HFACS

Focuses on four areas of human performance Acts Preconditions to Acts Supervision Organizational

Influences


Acts

or

Error

Lack of skill

Lack of education/training

Poor decision making

misperception

Violation

Willfuldisregard for

rules

&

regulations


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


Supervision

Adequate or inadequate

Failure to correct Planned

inappropriate ops Effect of

freelancing


Organizational Influences

Most difficult to assess Need to “read between

the lines” Resources Departmental climate SOPs (or lack of)


Near MissNear Miss

Latent Conditions

Latent Conditions

Latent Conditions

Active Conditions

Failed orAbsent Defenses

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Modified from Shappell & Wiegmann, JSSC 1997

Reason’s Swiss Cheese

Acts


Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ViolationsErrorsErrors

Exceptional

RoutinePerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe Acts


Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

DecisionErrors

DECISION ERROR Rule-based - Misapplication of a good rule - Application of a bad rule Knowledge-based - Inaccurate or incomplete

knowledge of the problemwww.firefighternearmiss.com

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Skill-BasedErrors

SKILL-BASEDERRORS

Attention Failures Memory Failure


Violations

Exceptional

Routine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

PERCEPTUALERRORS

Misjudge Distance Misread Cues Spatial Disorientation Visual Illusions


Exceptional

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ROUTINE VIOLATIONSHabitual departures

from rules condoned by management


Routine

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Perceptual

Errors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

Exceptional

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

EXCEPTIONAL VIOLATIONS Isolated departures from rules NOT condoned by management


Preconditions


Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

Substandard Practices

of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Interpersonal Resource

Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations

Adverse Mental States

Preconditionsfor

Unsafe Acts

UnsafeActs


Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators


of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s


Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations


Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS


ADVERSE MENTAL STATE Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation


Substandard

Conditions of

Operators

Substandard

Conditions of

Operators


of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s


Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations


Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Adverse Physiologic

al States

ADVERSE PHYSIOLOGICALSTATES

CO poisoning Medical Illness Intoxication


Substandard

Conditions of

Operators

Substandard

Conditions of

Operators


of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s


Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations


Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Physical/Mental

Limitations

PHYSICAL/MENTALLIMITATIONS

Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude


Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators


of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s


Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations



of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS


Mismanagement

INTERPERSONAL RESOURCEMISMANAGEMENT

Not Working as a Team Poor crew Coordination Improper Briefing Before a Mission Inadequate Coordination of Ops


Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators


of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s


Mismanagement

Adverse Physiologic

al States

Physical/Mental

Limitations



of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

PERSONAL READINESSReadiness Violations

Inadequate Pre-shift Rest

Bottle-to-Brief Rules Self-Medicating

Poor Judgement Poor Dietary Practices Overexertion While Off

Duty Excessive “Voluntary”

PTwww.firefighternearmiss.com

The Officer’s Role


InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnforeseenUnforeseen Known

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs


UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs



Operations



UNSAFESUPERVISION

UNSAFESUPERVISION



UNSAFESUPERVISION

UNSAFESUPERVISION

Known

INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance


UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs



Operations



UNSAFESUPERVISION

UNSAFESUPERVISION



Operations

UNSAFESUPERVISION

UNSAFESUPERVISION

Known

PLANNED INAPPROPRIATEOPERATIONS

Improper Work Tempo Poor Crew Pairing


UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs



Operations



UNSAFESUPERVISION

UNSAFESUPERVISION



UNSAFESUPERVISION

UNSAFESUPERVISION

Known

FAILED TO CORRECT AKNOWN PROBLEM

Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard


UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs



Operations



UNSAFESUPERVISION

UNSAFESUPERVISION



UNSAFESUPERVISION

UNSAFESUPERVISION

Known

SUPERVISORY VIOLATIONS Not Adhering to Rules and Regulations Willful Disregard for Authority by Supervisors


The Organization’s Role



UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES



UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs


ResourceManagement

ResourceManagement

OperationalProcess


ResourceManagement

ResourceManagement


RESOURCE MANAGEMENT Human Monetary Equipment/Facility



UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs


ResourceManagement

ResourceManagement

OperationalProcess




ORGANIZATIONALCLIMATE Structure Policies Culture



UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs


ResourceManagement

ResourceManagement

OperationalProcess


OperationalProcess


OPERATIONALPROCESS Operations Procedures Oversight


QUESTIONS?



Human Factors Analysis and Classification System HFACS A tool to promote a safer fire service.

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