Human beings by their very nature make mistakes
“Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance. ” Shappell & Wiegmann, 1997
Active versus Latent Failures (Reason, 1990) Organizational Factors Latent Conditions w. Budget cuts w. Excess workload Unsafe Supervision Latent Conditions w. Deficient training program w. Improper supervision Preconditions for Unsafe Acts Latent Conditions w. Poor training w. Mental Fatigue Unsafe Acts Failed or Absent Defenses Active Conditions w. Failed to ensure surface could hold backhoe w. Loss of situational awareness Accident & Injury w Sunk Backhoe into mud
UNSAFE ACTS Violations Errors Decision Errors Unsafe Acts Skill-Based Errors Perceptual Errors Routine Exceptional
UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors DECISION ERROR Unsafe Acts Ø Rule-based Decisions - If X, then do Y - Highly Procedural Ø Choice Decisions - Knowledge-based Ø Structured Decisions - Problem solving Routine Exceptional
UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors Routine SKILL-BASED ERRORS Unsafe Acts Ø Attention Failures - Breakdown in visual scan - Inadvertent operation of control - Failure to see and avoid Ø Memory Failure - Omitted item in process - Omitted step in procedure Exceptional
UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors PERCEPTUAL ERRORS Unsafe Acts Ø Misjudge Distance, speed, weight, etc. Ø Loss of situational awareness Ø Visual Illusions Routine Exceptional
UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors Routine ROUTINE (INFRACTIONS) (Habitual departures from rules condoned by management) Unsafe Acts ä Violation of Manuals/Policies/SOPs - Failed to Inspect Equipment Prior to Use - Violated Seatbelt Policy - Failed to Comply with Tie Down Requirements - Conducted Unauthorized Procedure with Equipment - Did not Conduct Tailgate Safety Meeting - Risk Assessment not Accomplished ä Failed to Adhere to Briefed Requirements ä Not Current/Qualified for Equipment ä Improper Procedure Exceptional
UNSAFE ACTS Violations Errors Decision Errors Skill-Based Errors Perceptual Errors Routine EXCEPTIONAL (Isolated departures from the rules not condoned by management) Unsafe Acts ä Violated Manuals/Policies/SOPs - Performed Unauthorized Operation - Horseplay with Equipment - Failed to Ensure Equipment was Operational - Allowed Unauthorized Operator - Ignored Equipment Malfunction ä Accepted Unnecessary Risk ä Not Current/Qualified for Equipment ä Exceeded Limits of Equipment Exceptional
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 Crew Resource Mismanagement Personal Readiness
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 Crew Resource Mismanagement ADVERSE MENTAL STATE Ø Ø Ø Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation Personal Readiness
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 Crew Resource Mismanagement ADVERSE PHYSIOLOGICAL STATES Ø Ø Ø Hypothermia Motion Sickness Fatigue Medical Illness Intoxication Personal Readiness
PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Substandard Practices of Operators Adverse Physiological States Physical/ Mental Limitations Preconditions for Unsafe Acts Crew Resource Mismanagement PHYSICAL/MENTAL LIMITATIONS Unsafe Acts Ø Ø Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude Personal Readiness
PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Preconditions for Unsafe Acts Interpersonal Resource Mismanagement CREW RESOURCE MISMANAGEMENT Ø Ø Not Working as a Team Poor Coordination/Communication Improper or No Tailgate Briefing Inadequate Coordination of Work Personal Readiness
PRECONDITIONS FOR UNSAFE ATS 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 PERSONAL READINESS Unsafe Acts Readiness Problems Ø Inadequate Rest Ø Excess Alcohol Consumption Ø Self-Medicating Poor Judgement Ø Poor Dietary Practices Ø Overexertion While Off Duty Ø Bad Habits Personal Readiness
UNSAFE SUPERVISION Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations
UNSAFE SUPERVISION Inadequate Supervision Unsafe Supervision Planned Inappropriate Operations Failed to Correct Problem INADEQUATE SUPERVISION Ø Failure to Administer Proper Training Ø Lack of Professional Guidance Preconditions for Unsafe Acts Supervisory Violations
UNSAFE SUPERVISION Inadequate Supervision Unsafe Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations PLANNED INAPPROPRIATE OPERATIONS Preconditions for Unsafe Acts Ø Ø Risk without Benefit No Risk Assessment Improper Work Tempo Poor Crew Pairing
UNSAFE SUPERVISION Inadequate Supervision Unsafe Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations FAILED TO CORRECT A KNOWN PROBLEM Ø Failure to Correct Inappropriate Behavior Ø Failure to Correct a Safety Hazard Ø Failure to Enforce Safety Rules Preconditions for Unsafe Acts
UNSAFE SUPERVISION Inadequate Supervision Unsafe Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations SUPERVISORY VIOLATIONS Preconditions for Unsafe Acts Ø Not Adhering to Rules and Regulations Ø Willful Disregard for Authority by Supervisors ØFailure to Conduct Risk Assessment
ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Operational Process
ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences RESOURCE MANAGEMENT Ø Human Ø Budget Ø Equipment/Facility Unsafe Supervision Preconditions for Unsafe Acts Operational Process
ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate ORGANIZATIONAL CLIMATE Organizational Influences Ø Structure Ø Policies Ø Culture Unsafe Supervision Preconditions for Unsafe Acts Operational Process
ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Influences OPERATIONAL PROCESS Unsafe Supervision Ø Operations Ø Procedures Ø Oversight Preconditions for Unsafe Acts Operational Process
ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Process UNSAFE SUPERVISION Planned Inappropriate Operations Inadequate Supervision Failed to Correct Problem Supervisory Violations PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Interpersonal Resource Mismanagement Personal Readiness UNSAFE ACTS Errors Decision Errors Skill-Based Errors Violations Perceptual Errors Routine Exceptional
“Whenever we talk about a worker who has been killed in an accident, we should all keep one thing in mind. They. . . made a judgment. They believed in it so strongly that they knowingly bet their life on it. That their judgment was faulty is a tragedy, … Every instructor, supervisor, and contemporary who ever spoke to them had the opportunity to influence their judgement, so a little bit of all of us goes with every worker we lose. ” --Anonymous
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