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

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


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.


Overview

• Why HFACS?

• What is HFACS?

• Using the tool.

Montgomery County Fire & Rescue (MD)


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


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


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


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


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

Error

• Lack of skill• Lack of

education/training• Poor decision

making• misperception

Violation

Willful

disregard for

rules

&

regulations

or


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)– “Telltale” words/phrases


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


Acts


Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ViolationsErrorsErrors

ExceptionalRoutinePerceptualErrors

DecisionErrors

Skill-BasedErrors


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


Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

Unsafe

Acts

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Skill-BasedErrors

SKILL-BASEDERRORS

Attention Failures Memory FailuresTechnique Failures


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


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 Individuals


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


Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators


of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s

Interpersonal Resource

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 Individuals


of Individuals

PRECONDITIONSFOR

UNSAFE ACTS


t

CREW RESOURCEMISMANAGEMENT

Failed to communicate Failed to use all resources Failed to recognize task limitations Failed to lead Failed to follow


Preconditionsfor

Unsafe Acts

UnsafeActs

Substandard

Conditions of

Operators

Substandard

Conditions of

Operators


of Operators


of Operators

PRECONDITIONSFOR

UNSAFE ACTS

Personal Readines

s


t

Adverse Physiologic

al States

Physical/Mental

Limitations



of Individuals


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


The Officer’s Role


InadequateSupervision

PermittedInappropriate

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


PlannedInappropriate

Operations



UNSAFESUPERVISION

UNSAFESUPERVISION



Operations

UNSAFESUPERVISION

UNSAFESUPERVISION

Known

PERMITTED INAPPROPRIATEOPERATIONS

Failed to Adequately Brief Understaffed Permitted Unnecessary Hazard Poor Crew Pairing


UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs



Operations



UNSAFESUPERVISION

UNSAFESUPERVISION



UNSAFESUPERVISION

UNSAFESUPERVISION

Known

FAILED TO CORRECT AKNOWN PROBLEM

Failed to recognize/id unqualified crew Failed to provide training Failed to correct freelancing


UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs



Operations



UNSAFESUPERVISION

UNSAFESUPERVISION



UNSAFESUPERVISION

UNSAFESUPERVISION

Known

SUPERVISORY VIOLATIONS Authorized Unnecessary Hazards Failed to Enforce Rules/Regs/SOPs Authorized unqualified crew to perform tasks


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?

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