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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 promotea safer
fire service
Saving Lives Through Experiences Shared
www.firefighternearmiss.com 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.
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Overview
• Why HFACS?
• What is HFACS?
• Using the tool.
Montgomery County Fire & Rescue (MD)
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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
H. W. Heinrich, 1930
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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
Accounta
bility
Comm
and
Comm
unicat
ion
Control a
nd Acco
untabi
lity
Decisi
on Mak
ing
Equipm
ent
Fatigue
Horsep
lay
Human
Erro
r
Indiv
idua
l Actio
n
Other
Proced
ure
Proto
col
Situatio
nal A
wareness
SOP /
SOG
Staffi
ng
Task A
lloca
tion
Teamw
ork
Train
ing Is
sue
Unknown
Weat
her
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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
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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 weren’t careful enough
Let’s also explore why the system allowed, or failed to accommodate your mistake
so
You should be PUNISHED! Let’s IMPROVE THE SYSTEM!
and
so
and
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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
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HFACS
• Focuses on four areas of human performance– Acts– Preconditions to Acts– Supervision– Organizational
Influences
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Acts
Error
• Lack of skill• Lack of
education/training• Poor decision
making• misperception
Violation
Willful
disregard for
rules
&
regulations
or
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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?
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Supervision
• Adequate or inadequate
• Failure to correct• Planned inappropriate
ops• Effect of freelancing
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Organizational Influences
• Most difficult to assess
• Need to “read between
the lines”– Resources– Departmental climate– SOPs (or lack of)– “Telltale” words/phrases
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Near Near MissMiss
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
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Acts
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Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ViolationsErrorsErrors
ExceptionalRoutinePerceptualErrors
DecisionErrors
Skill-BasedErrors
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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 problem
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Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
Skill-BasedErrors
SKILL-BASEDERRORS
Attention Failures Memory FailuresTechnique Failures
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Violations
Exceptional
Routine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
PERCEPTUALERRORS
Underestimated critical incident factors Misinterpreted CIRs Visual Illusions
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Exceptional
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ROUTINE VIOLATIONSHabitual departures
from rules condoned by management
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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
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Preconditions
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Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Individuals
Substandard Practices
of Individuals
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Crew Resource Mismanagemen
t
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Preconditionsfor
Unsafe Acts
UnsafeActs
www.firefighternearmiss.com The National Fire Fighter Near-Miss Reporting System
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Adverse Mental States
ADVERSE MENTAL STATE
Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation
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Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
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
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Adverse Physiologic
al States
ADVERSE PHYSIOLOGICALSTATES
CO poisoning Medical Illness Intoxication
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Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
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
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
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Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard Practices
of Individuals
Substandard Practices
of Individuals
PRECONDITIONSFOR
UNSAFE ACTS
Crew Resource Mismanagemen
t
CREW RESOURCEMISMANAGEMENT
Failed to communicate Failed to use all resources Failed to recognize task limitations Failed to lead Failed to follow
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Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Crew Resource Mismanagemen
t
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard Practices
of Individuals
Substandard Practices
of Individuals
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”
PT
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The Officer’s Role
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InadequateSupervision
PermittedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
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UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PermittedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
InadequateSupervision
UNSAFESUPERVISION
UNSAFESUPERVISION
Known
INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance
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UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
PermittedInappropriate
Operations
UNSAFESUPERVISION
UNSAFESUPERVISION
Known
PERMITTED INAPPROPRIATEOPERATIONS
Failed to Adequately Brief Understaffed Permitted Unnecessary Hazard Poor Crew Pairing
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UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
Failed toCorrectProblem
UNSAFESUPERVISION
UNSAFESUPERVISION
Known
FAILED TO CORRECT AKNOWN PROBLEM
Failed to recognize/id unqualified crew Failed to provide training Failed to correct freelancing
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UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
Known
SUPERVISORY VIOLATIONS Authorized Unnecessary Hazards Failed to Enforce Rules/Regs/SOPs Authorized unqualified crew to perform tasks
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The Organization’s Role
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OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
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OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
ResourceManagement
ResourceManagement
ORGANIZATIONALINFLUENCES
RESOURCE MANAGEMENT Human Monetary Equipment/Facility
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OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
OrganizationalClimate
ORGANIZATIONALINFLUENCES
ORGANIZATIONALCLIMATE Structure Policies Culture
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OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
OperationalProcess
ORGANIZATIONALINFLUENCES
OPERATIONALPROCESS Operations Procedures Oversight
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QUESTIONS?