A Data-Driven Approach to Managing Human Factors … · A Data-Driven Approach to Managing Human...
Transcript of A Data-Driven Approach to Managing Human Factors … · A Data-Driven Approach to Managing Human...
A DataA Data--Driven Approach to ManagingDriven Approach to ManagingHuman Factors within the Mining IndustryHuman Factors within the Mining Industry
Scott A. Shappell, Ph.D.ProfessorClemson UniversityDepartment of Industrial Engineering
Engineering Tools and TechniquesEngineering Tools and Techniques
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Mon
itor
Mon
itor
Safety Management ProcessSafety Management Process
Proven tools and techniques -Interventions are needs-based and data-driven
Engineering data is available to evaluate interventions before implementation
Accidents, Incidents, FOQA data, Service Reports, Modeling Data
Organized databases. Sophisticated and effective tools for analyzing data
Human FactorsHuman Factors
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Mon
itor
Mon
itor
Safety Management ProcessSafety Management Process
Proven tools and techniques -Interventions are needs-based and data-driven
Engineering data is available to evaluate interventions before implementation
Accidents, Incidents, FOQA data, Service Reports, Modeling Data
Organized databases. Sophisticated and effective tools for analyzing data
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Mon
itor
Mon
itor
Safety Management ProcessSafety Management Process
Proven tools and techniques -Interventions are needs-based and data-driven
Engineering data is available to evaluate interventions before implementation
Accidents, Incidents, FOQA data, Service Reports, Modeling Data
Organized databases. Sophisticated and effective tools for analyzing data
Human FactorsHuman Factors
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Mon
itor
Mon
itor
Safety Management ProcessSafety Management Process
Proven tools and techniques -Interventions are needs-based and data-driven
Engineering data is available to evaluate interventions before implementation
Accidents, Incidents, FOQA data, Service Reports, Modeling Data
Organized databases. Sophisticated and effective tools for analyzing data
Human FactorsHuman Factors
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Mon
itor
Mon
itor
Safety Management ProcessSafety Management Process
Proven tools and techniques -Interventions are needs-based and data-driven
Engineering data is available to evaluate interventions before implementation
Accidents, Incidents, FOQA data, Service Reports, Modeling Data
Organized databases. Sophisticated and effective tools for analyzing data
Human FactorsHuman Factors
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Pret
end
to M
onito
rPr
eten
d to
Mon
itor
Safety Management ProcessSafety Management Process
Proven tools and techniques -Interventions are needs-based and data-driven
Engineering data is available to evaluate interventions before implementation
Accidents, Incidents, FOQA data, Service Reports, Modeling Data
Organized databases. Sophisticated and effective tools for analyzing data
Human FactorsHuman Factors
InputsInputs
Adapted from Reason (1990)
Accident & InjuryAccident & Injury
“Swiss-cheese” Model of Human Error“Swiss-cheese” Model of Human Error
OrganizationalFactors
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Failed orFailed orAbsent DefensesAbsent Defenses
Human Factors Analysis and Classification System
®
Unsafe Unsafe \\InappropriateInappropriate
ActsActs
Routine Exceptional
ViolationsViolationsErrorsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
Unsafe / Unsafe / InappropriateInappropriate
ActsActs
Routine Exceptional
ViolationsViolationsErrorsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
DECISION ERRORS
Rule-based DecisionsChoice DecisionsIll-Structured Decisions
Human Factors Analysis and Classification System
®
Unsafe / Unsafe / InappropriateInappropriate
ActsActs
Routine Exceptional
ViolationsViolationsErrorsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
SKILL-BASED ERRORS
Attention FailuresMemory FailuresTechnique Errors
Human Factors Analysis and Classification System
®
Unsafe / Unsafe / InappropriateInappropriate
ActsActs
Routine Exceptional
ViolationsViolationsErrorsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
PERCEPTUAL ERRORS
MisperceptionsMisjudgments
Human Factors Analysis and Classification System
®
Unsafe / Unsafe / InappropriateInappropriate
ActsActs
Routine Exceptional
ViolationsViolationsErrorsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
ROUTINE VIOLATIONS(Habitual departures from rules condoned by management)
Violated training rulesFailed to comply with departmental manualsViolation of orders, regulations, and/or SOPs
Human Factors Analysis and Classification System
®
Unsafe /Unsafe /InappropriateInappropriate
ActsActs
Routine Exceptional
ViolationsViolationsErrorsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
EXCEPTIONAL VIOLATIONS(Isolated departures from the rules not condoned by management)
Performed unauthorized operationAccepted unauthorized hazardNot current/qualified
Human Factors Analysis and Classification System
®
Human Factors Analysis and Classification System
®
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CommunicationCoordination& Planning
Fitness forDuty
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CommunicationCoordination& Planning
Fitness forDuty
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
ADVERSE MENTAL STATESComplacencyStressOverconfidenceMental fatigueDistractionConfusion
Human Factors Analysis and Classification System
®
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CommunicationCoordination& Planning
Fitness forDuty
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
ADVERSE PHYSIOLOGICAL STATES
Physical fatigueSpatial disorientationVisual IllusionsHypoxiaMedical illness
Human Factors Analysis and Classification System
®
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CommunicationCoordination& Planning
Fitness forDuty
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
PHYSICAL/MENTAL LIMITATIONS
Visual limitationsHearing limitationNot current/qualifiedIncompatible physical capabilityIncompatible intelligence/aptitude
Human Factors Analysis and Classification System
®
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CommunicationCoordination& Planning
Fitness forDuty
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
CommunicationCoordination & Planning
Failed to conduct adequate briefLack of teamworkPoor communication/coordinationFailure of leadership
Human Factors Analysis and Classification System
®
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CommunicationCoordination& Planning
Fitness forDuty
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
PERSONAL READINESSCrew Rest RequirementsBottle-to-Brief RulesSelf-MedicatingPoor Dietary PracticeOverexertion While Off DutyInadequate preparation/skill
Human Factors Analysis and Classification System
®
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CommunicationCoordination& Planning
Fitness forDuty
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
PHYSICAL ENVIRONMENTWeatherLightingNoiseHeatVibration
Human Factors Analysis and Classification System
®
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CommunicationCoordination& Planning
Fitness forDuty
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
TECHNOLOGICAL ENVIRONMENT
Equipment and controlsAutomation reliability/complexityTask and Procedure DesignManuals and Checklist DesignInterfaces and Displays
Human Factors Analysis and Classification System
®
Human Factors Analysis and Classification System
®
Human Factors Analysis and Classification System
®
SupervisionSupervision
SupervisoryViolations
InadequateSupervision
PlannedInappropriate
Activities
Failed toCorrectProblem
SupervisionSupervision
SupervisoryViolations
InadequateSupervision
PlannedInappropriate
Activities
Failed toCorrectProblem
INADEQUATE SUPERVISIONFailure to Administer Proper TrainingLack of Professional GuidanceFailure to Provide Oversight
Human Factors Analysis and Classification System
®
SupervisionSupervision
SupervisoryViolations
InadequateSupervision
PlannedInappropriate
Activities
Failed toCorrectProblem
PLANNED INAPPROPRIATEACTIVITIES
Risk outweighs benefitsExcessive tasking/workloadPoor Crew Pairing
Human Factors Analysis and Classification System
®
SupervisionSupervision
SupervisoryViolations
InadequateSupervision
PlannedInappropriate
Activities
Failed toCorrectProblem
FAILED TO CORRECT AKNOWN PROBLEM
Failure to Correct Inappropriate BehaviorFailure to Correct a Safety Hazard
Human Factors Analysis and Classification System
®
SupervisionSupervision
SupervisoryViolations
InadequateSupervision
PlannedInappropriate
Activities
Failed toCorrectProblem
SUPERVISORY VIOLATIONSFailed to enforce the rulesAuthorized unnecessary hazardAuthorized unqualified crew for flight
Human Factors Analysis and Classification System
®
Human Factors Analysis and Classification System
®
OrganizationalOrganizationalInfluencesInfluences
ResourceManagement
OrganizationalClimate
OperationalProcess
OrganizationalOrganizationalInfluencesInfluences
ResourceManagement
OrganizationalClimate
OperationalProcess
RESOURCE MANAGEMENTHumanMonetaryEquipment/Facility
Human Factors Analysis and Classification System
®
OrganizationalOrganizationalInfluencesInfluences
ResourceManagement
OrganizationalClimate
OperationalProcess
ORGANIZATIONAL CLIMATEStructurePoliciesCulture
Human Factors Analysis and Classification System
®
OrganizationalOrganizationalInfluencesInfluences
ResourceManagement
OrganizationalClimate
OperationalProcess
OPERATIONAL PROCESSOperationsProceduresOversight
Human Factors Analysis and Classification System
®
Unsafe /Unsafe /InappropriateInappropriate
ActsActs
Routine Exceptional
ViolationsViolationsErrorsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
CRM/Interpersonal
Factors
PersonalReadiness
Personal/Personal/InterpersonalInterpersonal
FactorsFactors
Condition ofCondition ofEmployeesEmployees
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalEnvironmentalFactorsFactors
SupervisionSupervision
SupervisoryViolations
InadequateSupervision
PlannedInappropriate
Activities
Failed toCorrectProblem
OrganizationalOrganizationalInfluencesInfluences
ResourceManagement
OrganizationalClimate
OperationalProcess
Human Factors Analysis and Classification System
®
U.S. NAVY/MARINE CORPSU.S. NAVY/MARINE CORPS
AVIATION ACCIDENT DATAAVIATION ACCIDENT DATA
USN/USMCMethodologyUSN/USMCUSN/USMCMethodologyMethodology
Analyzed all Class A Mishaps between FY91Analyzed all Class A Mishaps between FY91--99 associated 99 associated with human error (n=178)with human error (n=178)Analyses included all human causal factors as identified in Analyses included all human causal factors as identified in the original investigation and endorsed by the Chain of the original investigation and endorsed by the Chain of CommandCommandNONO new causal factors were identifiednew causal factors were identifiedRatersRaters
2 Aerospace Psychologists2 Aerospace Psychologists2 Flight Surgeons2 Flight SurgeonsAirframe Rated Pilot/NFO Subject Matter ExpertsAirframe Rated Pilot/NFO Subject Matter Experts
Consensus ratingConsensus rating
Human Factors Analysis and Classification System
®
UnsafeUnsafeActsActs
Routine Exceptional
ViolationsViolationsErrorsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
Percentage of Human Error Mishaps Associated with Violations (FY 91-97)Percentage of Human Error Mishaps Associated with Violations (FY 91-97)
U.S. Army Mean
U.S. Navy/Marine Corps Mean
0
10
20
30
40
50
60
70
80
91 92 93 94 95 96 97Fiscal Year
Perc
enta
g e
U.S. Air Force Mean
OK Doc, Go Fix It!OK Doc, Go Fix It!
Flight DataRecorders
Engineers Pilots
Flight DocsAdministrators
AccountabilityEnforce the
Rules
IncreaseSupervision
Counsel the “rogue” pilot
AwarenessTraining
Better PilotSelection
Change theRules
Get rid of the“bad apples”
Professionalism
LimitAutonomy
Automate the Pilot out of Loop
GPWS
WeatherDisplays
CockpitCameras
Violations
UnsafeActs
Routine Exceptional
ViolationsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts
Crew ResourceCrew ResourceManagementManagement
PersonalPersonalReadinessReadiness
PersonnelPersonnelFactorsFactors
Condition ofCondition ofOperatorsOperators
AdverseAdverseMental StatesMental States
AdverseAdversePhysiologicalPhysiological
StatesStates
Physical/Physical/MentalMental
LimitationsLimitations
PhysicalPhysicalEnvironmentEnvironment
TechnologicalTechnologicalEnvironmentEnvironment
EnvironmentalEnvironmentalFactorsFactors
UnsafeUnsafeSupervisionSupervision
SupervisorySupervisoryViolationsViolations
InadequateInadequateSupervisionSupervision
PlannedPlannedInappropriateInappropriate
OperationsOperations
Failed toFailed toCorrectCorrectProblemProblem
OrganizationalOrganizationalInfluencesInfluences
ResourceResourceManagementManagement
OrganizationalOrganizationalClimateClimate
OperationalOperationalProcessProcess
Human Factors Analysis and Classification System
®
Environment (Hazard) -CenteredTechnology-CenteredTask-CenteredHuman-CenteredAdministrative/Org-Centered
Environment (Hazard) -CenteredTechnology-CenteredTask-CenteredHuman-CenteredAdministrative/Org-Centered
DecisionDecisionErrorsErrors
SkillSkill--basedbasedErrorsErrors
PerceptualPerceptualErrorsErrors
ViolationsViolations
Organizational/ Organizational/ AdministrativeAdministrative
Human/ Human/ CrewCrew
Technology/ Technology/ EngineeringEngineering
Task/ Task/ MissionMission
Operational/Operational/Physical Physical
EnvironmentEnvironment
Enforcement
Limit Autonomy
Pilot Selection
Counseling
Synthetic Vision
Weather Displays
Cockpit Cameras
Flight Data RecordersAwareness Training
Accountability
Increase Supervision
GPWS
Need for Low-level Flight (EA-6B)
Detachment Mentality (SH-60)
Training in Restricted Areas
Only
Procedures for Fuel Dumping/Burn
Human Factors Intervention matriXHFIX
®
Initial Intervention StrategyInitial Intervention Strategy
ProfessionalismProfessionalismAccountabilityAccountabilityEnforcing the RulesEnforcing the RulesDetachment SupervisionDetachment Supervision
Tracking Human Factors Intervention StrategiesTracking Human Factors Intervention Strategies
Data-drivenIntervention
0
10
20
30
40
50
60
70
80
91 92 93 94 95 96 97 98 99Fiscal Year
Perc
enta
g e
Previous U.S. Navy/Marine Corps Mean
00
Data-drivenIntervention
0
10
20
30
40
50
60
70
80
90
100
91 92 93 94 95 96 97 98 99 00Fiscal Year
Perc
enta
g e
Previous Trend
Interventions• Focus on tactical decision-making• Improved procedure development• Scenario-based training• Approach Magazine – Increased
awareness
Percentage of Human Error Mishaps Associated withDecision Errors (FY 91-00)
Percentage of Human Error Mishaps Associated withDecision Errors (FY 91-00)
0
10
20
30
40
50
60
70
80
90
100
91 92 93 94 95 96 97 98 99 00 01 02 03Fiscal Year
Perc
enta
g e
Previous Trend
Data-drivenIntervention
Percentage of Human Error Mishaps Associated withSkill-based Errors (FY 91-03)
Percentage of Human Error Mishaps Associated withSkill-based Errors (FY 91-03)
Interventions:• Improve instrument scan• Prioritizing attention• Recognizing extremis situations• Refine basic flight skills (Stick-and-Rudder)• Practice procedures• Review the mishap database!
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Pret
end
to M
onito
rPr
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d to
Mon
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Safety Management ProcessSafety Management Process ScienceScienceServicesServices
Field ToolField ToolInvestigator TrngInvestigator Trng
HFACS AnalysisHFACS Analysis
IdentifyIdentifyVulnerabilitiesVulnerabilities
Human Factors Analysis and Classification System
®
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Pret
end
to M
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rPr
eten
d to
Mon
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Safety Management ProcessSafety Management Process ScienceScienceServicesServices
Focus Groups
FeasibilityPrioritize
Field ToolField ToolInvestigator TrngInvestigator Trng
HFACS AnalysisHFACS Analysis
IdentifyIdentifyVulnerabilitiesVulnerabilities
Human Factors Analysis and Classification System
®
Human Factors Intervention matriXHFIX ®
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Pret
end
to M
onito
rPr
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d to
Mon
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Safety Management ProcessSafety Management Process ScienceScienceServicesServices
Focus Groups
FeasibilityPrioritize
Field ToolField ToolInvestigator TrngInvestigator Trng
HFACS AnalysisHFACS Analysis
IdentifyIdentifyVulnerabilitiesVulnerabilities
Human Factors Analysis and Classification System
®
Human Factors Intervention matriXHFIX ®
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Pret
end
to M
onito
rPr
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d to
Mon
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Safety Management ProcessSafety Management Process ScienceScienceServicesServices
Identify/DevelopIdentify/DevelopHF ProgramsHF Programs HF ConsultingHF Consulting
Focus Groups
FeasibilityPrioritize
Field ToolField ToolInvestigator TrngInvestigator Trng
HFACS AnalysisHFACS Analysis
IdentifyIdentifyVulnerabilitiesVulnerabilities
Human Factors Analysis and Classification System
®
Human Factors Intervention matriXHFIX ®
HazardIdentification
HazardIdentification
HazardAssessment
HazardAssessment
IdentifyInterventions
IdentifyInterventions
InterventionAssessment
InterventionAssessment
InterventionImplementation
InterventionImplementation
DataData
Mon
itor
Mon
itor
Safety Management ProcessSafety Management Process ScienceScienceServicesServices
Identify/DevelopIdentify/DevelopHF ProgramsHF Programs HF ConsultingHF Consulting
Focus Groups
FeasibilityPrioritize
Field ToolField ToolInvestigator TrngInvestigator Trng
HFACS AnalysisHFACS Analysis
IdentifyIdentifyVulnerabilitiesVulnerabilities
Human Factors Analysis and Classification System
®
Human Factors Intervention matriXHFIX ®
Human Factors Analysis and Classification System
®
Royal Netherlands Air Force
Indian Air Force
Canadian Air ForceCanadian Air Force