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HFACS Who Would Have Thought? Scott A. Shappell, Ph.D. HUMAN - - PowerPoint PPT Presentation
HFACS Who Would Have Thought? Scott A. Shappell, Ph.D. HUMAN - - PowerPoint PPT Presentation
HFACS Who Would Have Thought? Scott A. Shappell, Ph.D. HUMAN FACTORS Necessity is the Mother of Invention HUMAN FACTORS Swiss Cheese Model of Human Error Inputs Organizational Influences Supervisory Factors Preconditions for
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HUMAN FACTORS
Inputs
Accident & Injury Organizational Influences Supervisory Factors Preconditions for Unsafe Acts Unsafe Acts Failed or Absent Defenses
Swiss Cheese Model of Human Error
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HUMAN FACTORS
Modest Beginnings
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HUMAN FACTORS
Unsafe Acts Routine Exceptional Violations Errors Decision Errors Skill-based Errors Perceptual Errors Preconditions for Unsafe Acts Communication Coordination Planning Fitness for Duty Personal/ Interpersonal Factors Condition of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Physical Environment Technological Environment Environmental Factors Supervision Supervisory Violations Inadequate Supervision Planned Inappropriate Activities Failed to Correct Problem Organizational Influences Resource Management Organizational Climate Operational Process
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HUMAN FACTORS
Aviation
Military (Shappell & Wiegmann, 2004; Li et al., 2004; Li & Harris, 2006;
Guar,2005; Li & Harris, 2007; Gibb & Olsen, 2008; Pagan & de Voogt, 2008; Paletz, 2009; Belland et al.,, 2010)
Commercial (Wiegmann & Shappell, 2001; Shappell et al., 2007; Li &
Harris, 2006; Li et al., 2008; Majumdar er al.,2009; Harris & Lee, 2011)
General Aviation (Wiegmann et al., 2005; Lenne et al., 2008; Dambier &
Hinkelbein, 2006; Guar, 2005; Lenné, et al., 2008; Li, Harris, & Yu, 2008 )
Unmanned Aerial Vehicles (Thompson, 2005; Tvaryanas,
Thompson, & Constable, 2006)
Aviation Maintenance (Krulak, 2004; Boquet et al., 2004; Rashid et
al., 2010)
Air Traffic Control (Scarborough, et al, 2005; Olsen & Shorrock, 2010)
Non-Aviation
Combat Operations (Jennings, 2008) Construction (Garrett & Teizer, 2009) Forensics (Wertheim, 2010) Mining (Patterson et al., 2010) Railway (Reinnach & Vaile, 2009; Baysari et al., 2008; Baysari et al., 2009) Maritime (Winters & Valaitis, 2005; Celik & Cebi, 2009; Xi et al., 2009;
Schröder-Hinrichs et al., 2011)
Medical (ElBardissi et al., 2007; Portalur, et al.., 2010) Petrochemical (Koo et al., 2009) Nuclear Power (Kim et al., 2008)
Expansion of HFACS
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HUMAN FACTORS
General Aviation
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HUMAN FACTORS
Skill-based Errors Perceptual Errors Decision Errors Violations
Percentage of Accidents Year
Percentages do not add up to 100%
General Aviation: Overall
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HUMAN FACTORS
ERROR CATEGORY OVERALL SEMINAL Frequency (%) Fatal Non-fatal Total Frequency (%) Fatal Non-fatal Total Directional Control 20 (0.50) 2018 (15.2) 2038 (11.8) 9 (0.57) 1326 (17.5) 1335 (14.6) Airspeed 713 (17.9) 1127 (8.5) 1840 (10.6) 302 (19.2) 605 (8.0) 907 (9.9) Stall/Spin 592 (14.9) 753 (5.7) 1345 (7.8) 84 (5.3) 144 (1.9) 228 (2.5) Aircraft Control 654 (16.5) 665 (5.0) 1319 (7.6) 311 (19.8) 429 (5.7) 740 (8.1) Compensation for winds 23 (0.6) 1046 (6.2) 1069 (6.2) 12 (0.8 859 (11.4) 871 (9.5)
General Aviation: Fine Grained Analysis (Skill-Based Errors)
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HUMAN FACTORS
Number of Cases Unsafe Act Precondition for Unsafe Act Unsafe Supervision Organizational Influence Data Set n n (%) n (%) n (%) n (%) Chinese Military Aviation 325 325 (100%) 265 (81.54%) 159 (48.92%) 110 (33.85%) Chinese Civil Aviation 35 35 (100%) 31 (88.57%) 28 (80.00%) 26 (74.29%) Critical Cases 161 161 (100%) 73 (45.34%) 7 (4.35%) 12 (7.45%) Entertainment 173 173 (100%) 107 (61.85%) 16 (9.25%) 2 (1.16%) Food Services 328 328 (100%) 265 (80.79%) 123 (37.5%) 7 (2.13%) Maintenance - Field 392 392 (100%) 161 (41.07%) 7 (1.79%) 14 (3.57%) Maintenance - Site 87 87 (100%) 50 (57.47%) 9 (10.34%) 2 (2.30%) Middle East Aviation 31 31 (100%) 20 (64.52%) 5 (16.13%) 4 (12.90%) Mining - Australian 475 475 (100%) 380 (80.00%) 163 (34.32%) 43 (9.05%) Mining - US 242 242 (100%) 216 (89.26%) 205 (84.71%) 128 (52.89%) Remotely Piloted Aircraft Operations 48 48 (100%) 43 (89.58%) 22 (45.83%) 38 (79.17%) US Commercial Aviation - FAR 121 143 143 (100%) 80 (55.94%) 14 (9.79%) 10 (6.99%) US Commercial Aviation - FAR 135 779 779 (100%) 556 (71.37%) 26 (3.34%) 25 (3.21%) US General Aviation - FAR 133 61 61 (100%) 26 (42.62%) 2 (3.28%) 0 (0.00%) US General Aviation - FAR 137 761 761 (100%) 392 (51.51%) 2 (0.26%) 2 (0.26%) US General Aviation - FAR 91 12516 12516 (100%) 7426 (59.33%) 477 (3.81%) 23 (0.18%) US Gyroplane Aviation 158 158 (100%) 103 (65.19%) 4 (2.53%) 0 (0.00%)
- 48.61%
1.91% 0.40%
- 58.13%
7.95% 4.96%
- 67.65%
14.00% 9.53% HFACS Tier Lower Confidence Interval Mean Upper Confidence Interval
Benchmarking
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HUMAN FACTORS
Benchmarking
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HUMAN FACTORS
Benchmarking
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HUMAN FACTORS
Benchmarking
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HUMAN FACTORS
Associations Between Categories
Red – Data not included Yellow – Data sampled
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HUMAN FACTORS
Associations Between Categories
Solid blue line – Significant Chi-Square, Odds Ratio, and Lower Relative Risk Dashed blue line – Significant Chi-Square and Odds Ratio Dashed orange line – Significant Chi-Square
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HUMAN FACTORS
Solid blue line – Significant Chi-Square, Odds Ratio, and Lower Relative Risk Dashed blue line – Significant Chi-Square and Odds Ratio Dashed orange line – Significant Chi-Square
Associations – Tier Jumping
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HUMAN FACTORS
Comparison with other Studies
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HUMAN FACTORS
Future Directions
Offshore Oil Drilling
- Gulf of Mexico
Forensic Science
- Latent Fingerprint Analyses
- Questioned Document Analyses
Medicine
- Sentinel Events
- Cardiovascular OR
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