A FAILURE ANALYSIS AND CLASSIFICATION SYSTEM Shappell and

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A FAILURE ANALYSIS AND CLASSIFICATION SYSTEM Shappell and Wiegmann, 1997

A FAILURE ANALYSIS AND CLASSIFICATION SYSTEM Shappell and Wiegmann, 1997

Organizational Influences Latent Conditions Unsafe Supervision Latent Conditions Preconditions for Unsafe Acts Latent Conditions

Organizational Influences Latent Conditions Unsafe Supervision Latent Conditions Preconditions for Unsafe Acts Latent Conditions Unsafe Acts Active Conditions Failed or Absent Defenses Accident & Injury Shappell and Wiegmann, 1997

UNSAFE ACTS Violations Errors Decision Errors Unsafe Acts Shappell and Wiegmann, 1997 Skill-Based Errors

UNSAFE ACTS Violations Errors Decision Errors Unsafe Acts Shappell and Wiegmann, 1997 Skill-Based Errors Perceptual Errors Routine Exceptional

UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors DECISION ERROR Unsafe Acts

UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors DECISION ERROR Unsafe Acts Shappell and Wiegmann, 1997 Ø Rule-based - Misapplication of a good rule - Application of a bad rule Ø Knowledge-based - Inaccurate or incomplete knowledge of the problem Routine Exceptional

UNSAFE ACTS Violations Errors Decision Errors Unsafe Acts Shappell and Wiegmann, 1997 Skill-Based Errors

UNSAFE ACTS Violations Errors Decision Errors Unsafe Acts Shappell and Wiegmann, 1997 Skill-Based Errors Perceptual Errors SKILL-BASED ERRORS Ø Attention Failures Ø Memory Failure Routine Exceptional

UNSAFE ACTS Violations Errors Decision Errors Unsafe Acts Shappell and Wiegmann, 1997 Skill-Based Errors

UNSAFE ACTS Violations Errors Decision Errors Unsafe Acts Shappell and Wiegmann, 1997 Skill-Based Errors Perceptual Errors PERCEPTUAL ERRORS Ø Misjudge Distance, Altitude, Airspeed Ø Spatial Disorientation Ø Visual Illusions Routine Exceptional

UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors ROUTINE VIOLATIONS Unsafe Acts

UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors ROUTINE VIOLATIONS Unsafe Acts Shappell and Wiegmann, 1997 Ø Habitual departures from rules condoned by management Routine Exceptional

UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors EXCEPTIONAL VIOLATIONS Unsafe Acts

UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors EXCEPTIONAL VIOLATIONS Unsafe Acts Shappell and Wiegmann, 1997 Ø Isolated departures from rules NOT condoned by management Routine Exceptional

Shappell and Wiegmann, 1997

Shappell and Wiegmann, 1997

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Interpersonal Resource Mismanagement Personal Readiness

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Interpersonal Resource Mismanagement ADVERSE MENTAL STATE Ø Loss of Situational Awareness Ø Circadian dysrhythmia Ø Alertness (Drowsiness) Ø Overconfidence Ø Complacency Ø Task Fixation Personal Readiness

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Interpersonal Resource Mismanagement ADVERSE PHYSIOLOGICAL STATES Ø Hypoxia Ø Motion Sickness Ø Medical Illness Ø Intoxication Personal Readiness

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Interpersonal Resource Mismanagement PHYSICAL/MENTAL LIMITATIONS Ø Lack of Sensory Input Ø Limited Reaction Time Ø Incompatible Physical Capabilities Ø Incompatible Intelligence/Aptitude Shappell and Wiegmann, 1997 Personal Readiness

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Interpersonal Resource Mismanagement INTERPERSONAL RESOURCE MISMANAGEMENT Ø Not Working as a Team Ø Poor Aircrew Coordination Ø Improper Briefing Before a Mission Ø Inadequate Coordination of Flight Personal Readiness

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe

PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Adverse Physiological States Substandard Practices of Operators Physical/ Mental Limitations Interpersonal Resource Mismanagement PERSONAL READINESS Readiness Violations Ø Crew Rest Requirements Ø Bottle-to-Brief Rules Ø Self-Medicating Poor Judgement Ø Poor Dietary Practices Ø Overexertion While Off Duty Ø Excessive “Voluntary” PT Personal Readiness

Shappell and Wiegmann, 1997

Shappell and Wiegmann, 1997

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Shappell and

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Shappell and

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Unsafe

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Unsafe Supervision INADEQUATE SUPERVISION Preconditions for Unsafe Acts Ø Failure to Administer Proper Training Ø Lack of Professional Guidance Unsafe Acts Shappell and Wiegmann, 1997 Supervisory Violations

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Unsafe

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Unsafe Supervision PLANNED INAPPROPRIATE OPERATIONS Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Ø Improper Work Tempo Ø Poor Crew Pairing Supervisory Violations

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Unsafe

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Unsafe Supervision FAILED TO CORRECT A KNOWN PROBLEM Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Ø Failure to Correct Inappropriate Behavior Ø Failure to Correct a Safety Hazard Supervisory Violations

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Unsafe

UNSAFE SUPERVISION Unforeseen Known Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Unsafe Supervision SUPERVISORY VIOLATIONS Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Ø Not Adhering to Rules and Regulations Ø Willful Disregard for Authority by Supervisors Supervisory Violations

Shappell and Wiegmann, 1997

Shappell and Wiegmann, 1997

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Operational Process

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences RESOURCE MANAGEMENT Ø Human Ø Monetary

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences RESOURCE MANAGEMENT Ø Human Ø Monetary Ø Equipment/Facility Unsafe Supervision Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Operational Process

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate ORGANIZATIONAL CLIMATE Organizational Influences Ø Structure Ø Policies

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate ORGANIZATIONAL CLIMATE Organizational Influences Ø Structure Ø Policies Ø Culture Unsafe Supervision Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Operational Process

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences OPERATIONAL PROCESS Unsafe Supervision Ø Operations

ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences OPERATIONAL PROCESS Unsafe Supervision Ø Operations Ø Procedures Ø Oversight Preconditions for Unsafe Acts Shappell and Wiegmann, 1997 Operational Process