1 human factors theory update 1 july 2014 2 34 this can only happen with the human element present...

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Human Factors Theory

Update 1 July 2014

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This can only happen with the human element present – The question is why ????

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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.

“Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

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Why Investigate the Human Factor

People Make Mistakes!

• Leading cause of accidents.• DA Pam 385-40 Army Accident Investigation and

Reporting– Materiel Factors – Environmental Factors– Human FactorsSystem Inadequacies (figure 2-1)

• Support• Standards• Training• Leader• Individual

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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

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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

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Org

aniz

atio

nal F

acto

rsUnsafe

Supervisi

on

Preconditions

Unsafe Acts

Where do we usually look to prevent accidents?

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Org

aniz

atio

nal F

ailu

res

Unsafe Superv

ision

Preconditions

Unsafe Acts

Where should we look to prevent accidents?

Operating Environment

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A HUMAN FACTORS APPROACH TO ACCIDENT A HUMAN FACTORS APPROACH TO ACCIDENT ANALYSIS AND PREVENTIONANALYSIS AND PREVENTION

Scott Shappell, Ph.D.Civil Aeromedical Institute

Douglas Wiegmann, Ph.D.University of Illinois

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Wiegmann-Shappell

Human Factors Analysis And

Classification System (HFACS)

OPNAV 3750.6R (Appendix O)

Naval Safety Center375 A Street Norfolk VA 23511-4399(757) 444-3520

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Errors

PerceptualErrors

Skill-BasedErrors

UNSAFEACTS

Errors

DecisionErrors

ExceptionalRoutine

Violations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnforeseenUnforeseen KnownKnown

UnrecognizedHazardousOperations


InadequateDocumentation/

Procedures


ProceduresInadequateSupervision

InadequateSupervision

PlannedInappropriateOperations


Failure toCorrect Problem


SupervisoryViolations


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Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ViolationsErrorsErrors

ExceptionalRoutinePerceptualErrors

Skill-basedErrors

DecisionErrors

80%

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Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

DecisionError

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Skill-BasedErrors

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

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Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

Skill-basedErrors

Skill-BasedErrors

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

DecisionErrors

DECISIONERRORS

Rule-based Decisions - If X, then do Y - Highly Procedural Choice Decisions - Knowledge-based Ill-Structured Decisions - Problem solving

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Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

Skill-BasedErrors

Decision Error

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

PERCEPTUALERRORS

Misjudge Distance, Altitude, Airspeed, Groundspeed, Azimuth Spatial Disorientation Visual Illusions

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Exceptional

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ROUTINE (INFRACTIONS)(Habitual departures from rules condoned by management)

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

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Routine

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

Exceptional

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

EXCEPTIONAL(Isolated departures from the rules not condoned

by management)

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

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PRECONDITIONSFOR

UNSAFE ACTS

Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations

Non-SupervisoryTolerance ofUnsafe Acts


CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness

Adverse Physiological

States


StatesAdverse

Mental States

Adverse Mental States

SubstandardConditions of

Operators


Operators

SubstandardPractices ofOperators


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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



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

PRECONDITIONS

FORUNSAFE ACTS

80%Unsafe Acts

Dig Deeper

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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



ADVERSE PHYSIOLOGICALSTATES

Medication Hypoxia Motion Sickness Medical Illness Intoxication

PRECONDITIONS

FORUNSAFE ACTS

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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



PHYSICAL/MENTALLIMITATIONS

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

PRECONDITIONS

FORUNSAFE ACTS

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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



CREW RESOURCEMANAGEMENT

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

PRECONDITIONS

FORUNSAFE ACTS

Big Problem in Aviation

Need Good Communication

Skills

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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



PRECONDITIONS

FORUNSAFE ACTS

SupervisorySupervisory CrewCrew Rank GradientRank Gradient

SUPERVISORY

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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



PRECONDITIONS

FORUNSAFE ACTS


CREW1972 Florida Everglades crash

20 cent light bulb

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Eastern Airlines Flight 401 Crashed Florida Everglades Lockheed L-1011 (101 Deaths)

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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



PRECONDITIONS

FORUNSAFE ACTS


RANK GRADIENTWashington, DC Jan 1982

Pilot failed to listen to CopilotCrash into the Potomac River

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Air Florida Flight 90 Crashed into the Potomac River Boeing 737-300 (74 Deaths)

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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



NON-SUPERVISORY TOLERANCE

Failure to report incidents of misconduct

Toleration of unsafe acts andbehaviors

PRECONDITIONS

FORUNSAFE ACTS

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Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

Physical/Mental

Limitations



CrewResource

Management

CrewResource

ManagementPersonal

Readiness

PersonalReadiness


States


StatesAdverse

Mental States



Operators


Operators



PERSONAL READINESSReadiness Violations

Crew Rest Requirements Bottle-to-Brief Rules Self-Medicating

Poor Judgement Poor Dietary Practices Overexertion While Off Duty Excessive “Voluntary” PT

PRECONDITIONS

FORUNSAFE ACTS

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UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

UNSAFESUPERVISION

UNSAFESUPERVISION





Procedures


Procedures



PlannedInappropriate

Operations


Operations





While empowering individuals to make decisions and function independently is certainly essential, this does not divorce the Leader from accountability

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UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs





Procedures


Procedures




Operations


Operations





UNRECOGNIZED HAZARDOUSOPERATIONS

Loss of Supervisory Situational Awareness “Don’t Know What YouDon’t Know”

Hazards go unseen/unrecognized Supervisor is over-tasked / untrained No mentorship / role model

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UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs





Procedures


Procedures




Operations


Operations





INADEQUATE DOCUMENTAION/PROCEDURES

Failure of standards No Standards Recognized “after the fact”

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UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs





Procedures


Procedures




Operations


Operations





INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance/Mentor

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UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs





Procedures


Procedures




Operations


Operations





PLANNED INAPPROPRIATEOPERATIONS

Mission Risk without Benefit Improper Work Tempo Poor Crew Pairing Poor Planning by Leaders

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UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs





Procedures


Procedures




Operations


Operations





FAILED TO CORRECT AKNOWN PROBLEM

Failure to Correct Inappropriate BehaviorFailure to Correct a Safety Hazard

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UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs





Procedures


Procedures




Operations


Operations





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

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OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

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UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs


ResourceManagement

ResourceManagement

OperationalProcess


ResourceManagement

ResourceManagement


RESOURCE MANAGEMENT Human Monetary Equipment/Facility

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UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs


ResourceManagement

ResourceManagement

OperationalProcess




ORGANIZATIONALCLIMATE Structure Policies Culture

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UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs


ResourceManagement

ResourceManagement

OperationalProcess


OperationalProcess


OPERATIONALPROCESS Operations Procedures Oversight

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Errors

PerceptualErrors

Skill-BasedErrors

UNSAFEACTS

Errors

DecisionErrors

ExceptionalRoutine

Violations

Substandard Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS

Substandard Conditions of

Operators

PRECONDITIONSFOR

UNSAFE ACTS


States

Physical/Mental

Limitations



Personal Readiness

Crew Resource Mismanagement

Substandard Practices of Operators

ResourceManagement


OrganizationalProcess


UNSAFESUPERVISION

UNSAFESUPERVISION





Procedures


ProceduresInadequateSupervision








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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?

SUMMARY

?

?

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Organizational Influences

Unsafe Supervisory Practices

Preconditions for Unsafe Acts

Unsafe Soldier Actions

Accident

Driver’s Training Program Failure.

Failed to Correct a Known Problem. Inadequate NCO Supervision. Inadequate Maintenance Supervision.

Fatigue. Inexperience. Support Failure.

Failure to Follow Procedure. Speeding Violation. Driving Blind. Driving Skill Error.

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.

A SOLDIER’S FAILURE MAY NOT BE DUE TO HIS OWN ACTIONS.

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Putting It All Together

Unsafe Acts

Organizational Factors

Unsafe Supervision

Preconditions for Unsafe

Acts

Present and Contributing

Present but notContributing

Special Observation

Unsafe Inputs to the Organization & an Unsafe Operating Environment

Wiegmann and Shappell, 1999

50Safe Acts

Safe Organizational

FactorsSafe

Supervision

Preconditionsfor Safe

Acts

Plug the holes & prevent the

accidents!

Mission Success

Safe Inputs to the Organization & a Safe Operating Environment

Wiegmann and Shappell, 1999

When we get it right!

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When we get it right?

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When we get it right?

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It is our belief that the Humans FactorsAnalysis and Classification System (HFACS) framework bridges the gap between theory and practice by providinginvestigators with a comprehensive, user friendly tool for identifying and classifying the human causes or aviation accidents.

Shappell and Wiegmann – February 2000

Conclusion

1 human factors theory update 1 july 2014 2 34 this can only happen with the human element present...

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