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

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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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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
Shappell@errorsolutions.com or Wiegmann@error
solutions.com.. You can also visit us online at
www.errorsolutions.com. 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
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