HUMAN FACTORS IN SAFETY MANAGEMENT SYSTEMS安全管理系统中的人为因素

航空发表于 2010-5-17 18:54:13

HUMAN FACTORS IN SAFETY MANAGEMENT SYSTEMS安全管理系统中的人为因素
 
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航空发表于 2010-5-17 18:54:31

Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 1 Copyright Error Management Solutions, LLC 2004 The need to manage human error comes as no great revelation to anyone involved in system safety. Truth be told, however, the “battle cry” that human error is associated with 60% to 80% of all accidents in complex, high-risk systems has become passé in many organizations. The reason behind this attitude is that human error statistics have not changed appreciably in more than a half century! So, while safety professionals can all agree that something must be done to reduce errors, a growing number of executives in the boardroom are becoming skeptical to the idea that something actually can be done. Unfortunately, most of us don’t have the luxury of embracing this liaise faire approach to safety. We are paid to prevent accidents, or at a minimum, mitigate their consequences. And although some stakeholders express cynicism while discussing safety behind closed doors, when an accident does occur, attitudes quickly change. Unfortunately, it is at these moments that safety engineers and managers finds themselves at the center of the storm answering very pointed questions like, “How could this have happened,” “Why didn’t you do anything to prevent it,” and “What are you going to do to prevent this from happening again?” As former safety officers and accident investigators ourselves, we too have felt the painful sting of the boss’ stare when an accident occurs. Perhaps that is why we have relentlessly pursued better ways to manage human error. Most safety professionals are very familiar with the traditional system safety approach illustrated in Figure 1. While there are many variants to the approach, most involve the following components: collecting data, identifying and assessing hazards, identifying/developing interventions, assessing intervention feasibility, intervention implementation, and system monitoring/program evaluation. Ideally, this is a dynamic process involving the real-time identification of hazards, deployment of interventions and hopefully, improvements in safety. Hazard Identification Hazard Assessment Identify Interventions Intervention Assessment Intervention Implementation Data Monitor Figure 1. The Safety Management Process “Managing human error is fundamental to maintaining the viability and profitability of any organization.” Wiegmann & Shappell “In high-risk industries, accidents are simply the cost of doing business.” Anonymous CEO “When the only tool you have is a hammer, every problem becomes a nail.” Anonymous HUMAN FACTORS IN SAFETY MANAGEMENT SYSTEMS Douglas A. Wiegmann, Ph.D. and Scott A. Shappell, Ph.D. Error Management Solutions, LLC Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 2 Copyright Error Management Solutions, LLC 2004 Historically, this traditional approach to system safety has been highly successful at addressing mechanical and engineering problems within a variety of operational contexts. Albeit, it has been facilitated by the development of a comprehensive set of engineering tools and techniques for implementing each step. Not surprising, given the success of system safety in the engineering world, many safety professionals have been quick to adopt this same approach when attempting to manage human error and other complex human factors issues. But, it hasn’t been working. Why? Unfortunately, the requisite tools and techniques for employing a system safety approach to human error management have been largely ineffectual or nonexistent. As a result, it has been virtually impossible to get beyond the first step in the process - data collection. In fact, when an accident or incident does happen, the most common response is simply to collect more data. However, merely gathering more data about the occurrence of errors is not the ultimate solution. Organizations have been busy collecting data for decades. In fact, most safety engineers and managers are swimming (or perhaps drowning) in data, particularly given recent advances in technology that have increased the amount of information available exponentially. Most safety professionals have become frustrated with just watching the human error “data bucket” fill up and are eager to get beyond this seemingly perpetual data collection rut. After all, implementing intervention programs that improve safety is the ultimate goal, and one should not confuse data collection with safety interventions! Left without useful tools for systematically studying the proverbial “boat load” of human error data, the only option available to safety managers is to bypass the next two highly critical steps in the system safety process. As illustrated in Figure 2, these steps that are often skipped involve the identification and assessment of hazards. Hazard Identification Hazard Assessment Identify Interventions Intervention Assessment Intervention Implementation Data Pretend to Monitor SSaaffeettyy Maannaaggeemmeenntt PPrroocceessss LLiimmiitteedd HHuummaann FFaaccttoorrss TToooollss aanndd TTeecchhnniiqquueess No tools/techniques -Interventions therefore based on “gut feelings” or personality driven Human factors data is not available to evaluate interventions “Data Bucket” filled from accidents, incidents, safety reports, etc. Poor tools to code, archive and analyze error data - key steps are therefore skipped Figure 2. Lack of effective human factors tools results in key steps in the safety process being skipped. The fact is, there has been no way to determine the common problems that exist throughout the entire system. As a result, the modus operandi of many organizations has been the process of simply “cherry picking” the hazards identified in the most recent incident or focusing on select “high profile” events that have captured everyone’s attention. However, these may have no real bearing on the most threatening systemic hazards that are lying dormant in the system (and most likely in your database as well). As a result, the forest is often missed for the trees. To make matters worse, there have been no effective tools for systematically generating effective intervention programs that target specific forms of human error. Consequently, as also illustrated in Figure 2, this has forced safety professionals to bypass the next key steps in the safety management process – generating and evaluating intervention strategies. Indeed, the typical process for ginning up error prevention programs is to use simple intuition, expert opinion, or “pop psychology.” Unfortunately, such an approach often results in people pushing their pet projects, or the person with the loudest voice or highest authority having the last say on what gets done. Hence, this entire engineering approach to human error management, although conceivably a good idea, has met with little success. “Insanity is doing the same thing over-andover again and expecting a different outcome.” Albert Einstein “Prescription without diagnosis is malpractice. Socrates “Intuition is no substitute for information.” Wiegmann & Shappell Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 3 Copyright Error Management Solutions, LLC 2004 Over the past several years, we have been working on ways to improve the integration of human factors into the system safety process. As both scientists and practitioners, we have strived to develop methods for managing human error that are scientifically derived, empirically tested, and proven in the field. The results of our efforts have been the successful development of a compendium of tools and techniques that turn errors into information, information into knowledge, and knowledge into effective error management solutions. The Human Factors Analysis and Classification System (HFACS®) is an empirically derived system-safety model that effectively bridges the gap between human error theory and the practice of applied human error analysis. A proven safety management tool, HFACS facilitates the reliable identification, classification, and analysis of human error in complex, high-risk systems such as aviation, healthcare, and nuclear power industries. As illustrated in Figure 3, the HFACS framework comprehensively addresses the myriad of active and latent failures known to influence operator performance. Latent Conditions Latent Conditions AAccttiivvee aanndd LLaatteenntt CCoonnddiittiioonnss Failed or Absent Defenses Organizational Factors Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Active Conditions Accident Figure 3. Model of latent and active failures. In doing so, HFACS allows safety professionals to identity all of the factors that influence performance and cause operators to err. As illustrated in Figure 4, these factors include cognitive and physiological variables, contextual and technological components, and communication and interpersonal interactions. Also included, but often overlooked, are those supervisory and organizational factors that directly influence the causal chain of events. In other words, the HFACS framework goes beyond the simple identification of what an operator did wrong to provide a clear understanding of the reasons why the error occurred in the first place. In this way, errors are viewed as consequences of system failures, and/or symptoms of deeper systemic problems. They are not simply the fault of the employee working the “pointy end of the spear.” Errors UNSAFE ACTS Perceptual Errors Skill-Based Errors Decision Errors Routine Exceptional Violations Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Resource Management Organizational Climate Organizational Process ORGANIZATIONAL INFLUENCES PRECONDITIONS FOR UNSAFE ACTS Condition of Operators Physical/ Mental Limitations Adverse Mental States Technological Environment Physical Environment Personal Readiness Crew Resource Management Personnel Factors Adverse Physiological States Environmental Factors Figure 4. The Human Factors Analysis and Classification System (HFACS). We originally developed HFACS as an aviation accident investigation and analysis tool for the U.S. Navy and Marine Corps. However, HFACS has since been adopted by all branches of the U.S. military, as well as the Canadian Defense Force as a tool for analyzing the role of human error in military aviation accidents. It is now also widely utilized by civil aviation organizations around the world, including the Federal Aviation Administration (FAA) and National Aeronautics and Space Administration (NASA), as an adjunct to their preexisting safety management systems. This is not to say that HFACS is only applicable to aviation. Indeed, it has also been proven effective in the analysis of errors within a variety of other industrial settings, including healthcare, mining, and manufacturing. Given its theoretical foundation, HFACS can be applied in virtually any operational context. Error Management Solutions Human Factors Analysis and Classification System ® Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 4 Copyright Error Management Solutions, LLC 2004 Identifying the causes of human error, however, is only half the battle in the prevention of incidents and accidents. The development and implementation of effective intervention programs that reduce the occurrence or consequences of errors is the next critical step in the safety management process. Toward these ends, we recently developed the tools and methodology for mapping intervention strategies onto specific forms of human error identified within the HFACS model. Our tool, coined the Human Factors Intervention matriX (HFIX®) allows safety professionals to systematically generate comprehensive intervention strategies that directly target specific error categories, as well as their underlying causes (see Figure 5). DDeecciissiioonn EErrrroorrss SSkkiillll--based EErrrroorrss PPeerrcceeppttuuaall EErrrroorrss VViioollaattiioonnss OOrrggaanniizzaattiioonnaall// Administrative Human/ CCrreeww Technology/ EEnnggiinneeeerriinngg TTaasskk// Mission Operational/ Physical EEnnvviirroonnmmeenntt Figure 5. The Human Factors Intervention matriX (HFIX). However, HFIX does not stop at simply identifying interventions. Rather, the model guides safety professionals when evaluating the potential efficacy of intervention strategies. For instance, as illustrated in Figure 6, other factors that need to be considered before implementing any intervention are cost, feasibility, and acceptability. All of these, and others, are captured during the process of applying the HFIX methodology. FFeeaassiibbiilliittyy Cost Effectiveness Organizational/ Administrative Human/ Crew Technology/ Engineering DDeecciissiioonn EErrrroorrss SSkkiillll-based EErrrroorrss PPeerrcceeppttuuaall EErrrroorrss Task/ Mission VViioollaattiioonnss Operational/ Physical Environment Acceptability Figure 6. The Human Factors Intervention matriX (HFIX) in three dimensions. Once the need for specific interventions has been identified and the feasibility of each has been assessed, the next step is to identify providers for these intervention programs. Unfortunately, in our experience we have seen too many organizations simply purchase “off the shelf” intervention packages that look good on the surface but have no scientific support to show that they actually work. Another common problem is that many vendors of human factors programs have little or no real expertise in human factors or the safety programs that they are selling. Rather, many are former operators whose only credentials are that they have attended human factors training as part of the their previous job. Worse yet, some are simply retired program managers who possess little, if any, knowledge of the content of the various human factors programs they managed. In the end, many vendors simply download materials off the web, modify them for a particular domain, and then market their wares as unique programs or panaceas for all that ails the unsuspecting organization. This is not to say that effective human factors safety programs don’t exist. They do! However, to get your money’s worth, you need to consult with recognized experts in the field rather than contracting with some potential charlatan whose only claim to fame is that he has been involved in safety for twenty years. The latter may have an Human Factors Intervention Programs HFIX Human Factors Intervention matriX ® Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 5 Copyright Error Management Solutions, LLC 2004 abundance of good “war stories” to tell, but it is only the former who can really help you address your problems and successfully apply the tools to complete the system safety loop. The systematic application of HFACS to the analysis of human errors, coupled with the methodical utilization of HFIX to generate intervention solutions, finally ensures that an organization’s limited personnel and monetary resources are utilized wisely. This occurs because such efforts are needs-based and data-driven. They therefore permit the completion of the system safety process, as illustrated in Figure 7. Ultimately, this allows for the true effectiveness of intervention programs to be objectively and impartially evaluated so that they can be either modified or reinforced to improve system performance. Seerrvviicceess Scciieenccee Hazard Identification Hazard Assessment Identify Interventions Intervention Assessment Intervention Implementation Data Safety Management Process HFIX Generate Targeted Interventions Feasibility Prioritize IIddeennttiiffyy//DDeevveelloopp HF Programs HF Consulting Monitor HFACS FFiieelldd TTooooll IInnvveessttiiggaattoorr TTrrnngg HHFFAACCSS AAnnaallyyssiiss IIddeennttiiffyy Vulnerabilities Figure 7. Human Factors in Safety Management Systems. CONCLUSION Managing human error is fundamental to the viability and profitability of any organization. However, the traditional system safety approach has not been effective at reducing errors in most complex systems. Innovative tools are required that can turn errors into information, information into knowledge, and knowledge into effective error management solutions. Such tools are now finally available and can help effectively integrate human factors into traditional safety management systems. Managing human error, which was once considered beyond the reach of safety professionals, has now been made possible through the scientific efforts of the founders of “Error Management Solutions, LLC.” Shappell, S.A. & Wiegmann, D.A. (2001). Applying Reason: The Human Factors Analysis and Classification System (HFACS). Human Factors and Aerospace Safety, 1(1), 59-86. Wiegmann, D. A. & Shappell, S.A. (2001). Human error analysis of commercial aviation accidents: Application of the Human Factors Analysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine, 72, 1006-1016. Wiegmann, D. A. & Shappell, S.A. (2001). Human error perspectives in aviation. The International Journal of Aviation Psychology, 11(4), 341-357. Wiegmann, D. A. & Shappell, S.A. (2003). Human error approach to aviation accident analysis: The Human Factors Analysis and Classification System. VT: Ashgate Press (ISBN 07546 1873 0). Dr. Douglas A. Wiegmann Dr. Douglas A. Wiegmann is co-founder and CEO of Error Management Solutions, LLC. He is also a tenured professor in the Department of Human Factors at the University of Illinois in Urbana-Champaign. Dr. Wiegmann is an internationally recognized expert in the fields of human error analysis and accident investigation. He formerly served as an aviation psychologist for the U.S. Navy and an accident investigator for the U.S. National Transportation Safety Board (NTSB). He was the official human factors consultant to the U.S. Department of Energy during the investigation of the August 2003 blackout and consultant to the Columbia About the Authors Bibliography Completing the System Safety Loop Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 6 Copyright Error Management Solutions, LLC 2004 Accident Investigation Board during their analysis of the causes underlying the crash of the NASA space shuttle. Dr. Wiegmann is a board certified human factors professional and Past-president of the Aerospace Human Factors Association. Dr. Scott Shappell Dr. Shappell is co-founder and President of Error Management Solutions, LLC. He is an internationally renowned expert and a highly sought after consultant and speaker in the fields of human factors, systems safety, error management, and accident investigation. He formerly served as Human Factors Branch Chief at the U.S. Naval Safety Center and as a human factors accident investigation consultant for the Joint Service Safety Chiefs. Prior to the Naval Safety Center, he served as the Force Aerospace Psychologist for the Commander, Naval Air Forces, U.S. Atlantic Fleet. His work experiences also include serving as the Human Factors Research Branch Manager at the Civil Aerospace Medical Institute of the Federal Aviation Administration in Oklahoma City, OK. He has published over 50 papers in the fields of human error analysis and accident investigation, workplace injuries, and fatigue. Dr. Shappell is a Fellow of the Aerospace Medical Association and Past-president of the Aerospace Human Factors Association. Recognized Experts in the Field Dr. Shappell and Dr. Wiegmann have received numerous awards from prestigious organizations for their significant contributions to error analysis and system safety. These include: Admiral Luis de Florez Award (2002) for significant contributions of aviation safety. Awarded by the Flight Safety Foundation, International. Harry G. Moseley Award (2003) for significant contributions to human factors and aerospace safety. Awarded by the Aerospace Medical Association. William B. Collins Award (2002) for best publication in the area of engineering psychology and human factors. Awarded by the Aerospace Human Factors Association. For more information, you can email us at <A href="mailto:Shappell@errorsolutions.com">Shappell@errorsolutions.com</A> or <A href="mailto:Wiegmann@error">Wiegmann@error</A> solutions.com.. You can also visit us online at <A href="http://www.errorsolutions.com">www.errorsolutions.com</A>. If you wish to speak to one of us in person, please call (405) 640-5479. We wrote the book on applied human error analysis! Title: A human error approach to aviation accident analysis: The human factors analysis and classification system (HFACS). Ashgate Press (ISBN: 07546 1873 0) Reviews 'Bridging the gap between system safety theory and practice, this book provides a clear, comprehensive, field-tested framework to assist aviation safety professionals with investigating, analyzing, and assessing the impact of human error in aviation accidents and incidents. A 'must-read' for all interested in causal factor analysis!' Dr. James T. Luxhøj, Rutgers University, USA '…it is the training in human error analysis using HFACS that has enabled our Naval Flight Surgeons to serve as the human factors experts…' Captain James R. Fraser, M.D., Command Surgeon, Naval Safety Center, Norfolk, Virginia. 'This book is essential reading for all safety professionals, investigators and analysts. Captain Nicholas Webster, MD, MPH, Aeromedical Safety Professional '…the book should be required reading for any journalist expected to cover air accidents. …it contains a wealth of insight and it will be a useful addition to the bookshelf of anyone with an interest in aviation safety. ' Navigation News Jan 04 Contact Us Now Available!

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HUMAN FACTORS IN SAFETY MANAGEMENT SYSTEMS安全管理系统中的人为因素

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