NearMiss Reporting PreCon

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

• Why HFACS?
• What is HFACS?
• Using the tool.

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Human Factors Analysis and Classification System

• (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.

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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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Why Study Near Misses?
1 Tragic Opportunity to learn
300 Survival Stories Opportunities to learn
1 Serious Accident
15 Major Accidents
300 Near Misses
15,000 Observed Worker Errors
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Contributing Factors

• Self reported.
• Confirmed by interview.
• Human elements lead list.

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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 peoples 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.
  

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To error is human . . .
How It Is Now . . .
How It Should Be . . .
You are human and
You are highly trained
and
Humans make mistakes so
If you did as trained, you would not make
mistakes
Lets also explore why the system allowed, or
failed to accommodate your mistake
so
You werent careful enough
so
and
You should be PUNISHED!
Lets IMPROVE THE SYSTEM!
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Reasons Swiss Cheese
Ill-defined SOPs Labor Issues Low Morale
Org. Influences
Unsafe Supervision
Task Allocation Failure to Correct Willful
Disregard
Preconditions
Unsafe Acts
Fatigue Complacency Loss of Situational Awareness
Crew Actions
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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)

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Reasons Swiss Cheese
Latent Conditions
Organizational Influences
Latent Conditions
Unsafe Supervision
Latent Conditions
Preconditions for Unsafe Acts
Active Conditions
Unsafe Acts
Failed or Absent Defenses
Near Miss
Modified from Shappell Wiegmann, JSSC 1997
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Acts
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Unsafe Acts
UNSAFE ACTS
Unsafe Acts
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UNSAFE ACTS
Errors
Violations
Perceptual Errors
Skill-Based Errors
Exceptional
Routine

• 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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UNSAFE ACTS
Errors
Violations
Perceptual Errors
Exceptional
Routine
Unsafe Acts

• Attention Failures
• Memory Failure

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UNSAFE ACTS
Errors
Violations
Perceptual Errors
Exceptional
Routine
Unsafe Acts

• Misjudge Distance
• Misread Cues
• Spatial Disorientation
• Visual Illusions

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Errors
Perceptual Errors
Exceptional
Unsafe Acts

• Habitual departures from rules condoned by
  management

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Errors
Perceptual Errors
Routine
Exceptional

• Isolated departures from rules
• NOT condoned by management

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Preconditions
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PRECONDITIONS FOR UNSAFE ACTS
Substandard Conditions of Operators
Substandard Practices of Operators
Adverse Physiological States
Physical/ Mental Limitations
Adverse Mental States
Interpersonal Resource Mismanagement
Personal Readiness

• Loss of Situational Awareness
• Circadian dysrhythmia
• Alertness (Drowsiness)
• Overconfidence
• Complacency
• Task Fixation

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Preconditions for Unsafe Acts
Unsafe Acts

• CO poisoning
• Medical Illness
• Intoxication

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Physical/ Mental Limitations

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

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

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Preconditions for Unsafe Acts
Unsafe Acts

• Readiness 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 Officers Role
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• Failure to Administer Proper Training
• Lack of Professional Guidance

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• Improper Work Tempo
• Poor Crew Pairing

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• Failure to Correct Inappropriate
• Behavior
• Failure to Correct a Safety Hazard

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

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The Organizations Role
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Organizational Influences
Unsafe Supervision
Preconditions for Unsafe Acts
Unsafe Acts
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• Human
• Monetary
• Equipment/Facility

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Organizational Influences
Unsafe Supervision
Preconditions for Unsafe Acts

• Structure
• Policies
• Culture

Unsafe Acts
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Organizational Influences
Unsafe Supervision
Preconditions for Unsafe Acts

• Operations
• Procedures
• Oversight

Unsafe Acts
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Human Factors Analysis and Classification System

• QUESTIONS?

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