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HUMAN FACTOR – Swiss Cheese Theory
FAKTOR MANUSIA DALAM K3
PERTEMUAN 6
PUTRI HANDAYANI, SKM, MKKK
PRODI KESMAS / FIKES
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TUJUAN/CAPAIAN PEMBELAJARAN
Menguraikan konsep Konsep swiss cheese model, dan
Lingkup pengamatan swiss cheese model
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Failed or
Absent Defenses
Organizational
Factors
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
Adapted from Reason
(1990)
Accident & Injury
Reason’s “Swiss-cheese” Model of Human Error
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Errors
ACTS
Errors
Perception
Errors
Skill-Based
Errors
Judgment and
Decision-Making
Errors
Violations
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
Resource/Acquisition
Management
Organizational
Climate
Organizational
Process
ORGANIZATIONAL
INFLUENCES
Condition of
Individuals
Cognitive
Factors
Technological
Environment
Physical
Environment
Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States
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Skill-based Errors: kesalahan dalam tugas-tugas rutin-dilakukan
Decision Errors: kesalahan dalam pemilihan tindakan untuk situasi tertentu
Perception Errors: persepsi yang mengarah kepada tindakan yang tidak tepat
Violation: sengaja bertindak melawan kebijakan tertulis atau prosedur.
Acts The act is the end result. It answers the question of, “what happened?”
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ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors
Unsafe
Acts
Unsafe
Acts
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DECISION ERRORS Risk Assessment – During
Operation
Task Misprioritization
Necessary Action – Rushed
Necessary Action – Delayed
Caution/Warning – Ignored
Wrong choice of action
ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors
Unsafe
Acts
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SKILL-BASED ERRORS
ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors
Inadvertent Operation
Checklist Error
Procedural Error
Overcontrol/Undercontrol
Breakdown in Visual Scan
Inadequate Anti-G Straining Maneuver
Unsafe
Acts
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MISPERCEPTION ERRORS
(due to) Misjudge Distance, Altitude, Airspeed
Spatial Disorientation
Visual Illusions
ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors
Unsafe
Acts
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ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors VIOLATIONS (Willful disregard for rules and instructions!)
Violation – Work-around
Violation – Routine/Widespread
Violation – Extreme
Unsafe
Acts
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Physical environment: lingkungan kerja. Hujan, gelap, dingin, panas, dll
Technological Environment: alat yang digunakan dalam misi. Desain kendaraan dan kegunaan dari sistem yang terkait
Self-imposed stress: alkohol, kurang tidur, tingkat kebugaran
Prakondisi adalah hal-hal yang memungkinkan tindakan tidak aman terjadi, dan mereka menjawab pertanyaan, "Mengapa hal itu bisa terjadi?" Kategorinya adalah:
Preconditions
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Condition of
Individuals
Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States
Cognitive
Factors
Preconditions
for
Unsafe Acts
Unsafe
Acts
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Condition of
Individuals
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States
PHYSICAL ENVIRONMENT Icing/Fog/Etc. on windows
Meteorological Conditions
Dust/Smoke/Etc. in Workspace
Brownout/Whiteout
Thermal Stress: Cold/Hot
Maneuvering Forces In-Flight
Noise Interference
Preconditions
for
Unsafe Acts
Unsafe
Acts
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Cognitive
Factors
Psycho-
Behavioral
Factors
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States
Technological
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Environmental
Factors
PRECONDITIONS
TECHNOLOGICAL
ENVIRONMENT Seating and Restraints
Instrument and Sensory Feedback
Visibility Restrictions
Controls and Switches
Automation
Personal Equipment Interference
Communications - Equipment
Physical
Environment Condition of
Individuals
Preconditions
for
Unsafe Acts
Unsafe
Acts
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Cognitive
Factors
Technological
Environment
Physical
Environment Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Adverse
Physiological
States
Physical/
Mental
Limitations
Perceptual
Factors
COORD/COMM/PLAN Crew/Team Leadership
Cross-Monitoring Performance
Task Delegation
Rank/Position Authority Gradient
Communicating Critical Info
Standard/Proper Terminology
Mission Planning/Briefing
Miscommunication
Condition of
Individuals
Self-
Imposed
Stress
Preconditions
for
Unsafe Acts
Unsafe
Acts
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Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Adverse
Physiological
States
Physical/
Mental
Limitations
Perceptual
Factors
SELF-IMPOSED STRESS
Alcohol Physical Fitness
Drugs/Supplements/Self
Medication
Nutrition
Inadequate Rest
Unreported Disqualifying Medical
Condition
Condition of
Individuals
Preconditions
for
Unsafe Acts
Unsafe
Acts
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COGNITIVE FACTORS Inattention
Channelized Attention
Cognitive Task Oversaturation
Confusion
Negative Transfer
Distraction
Geographic Misorientation (Lost)
Checklist Interference
Condition of
Individuals
Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States Preconditions
for
Unsafe Acts
Unsafe
Acts
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PSYCHO-BEHAVIORAL Personality Style
Pre-Existing Personality Disorder
Pre-Existing Psychological Disorder
Emotional State
Overconfidence
Complacency
Get-Home-Itis/Get-There-Itis
Overaggressive
Condition of
Individuals
Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States Preconditions
for
Unsafe Acts
Unsafe
Acts
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ADVERSE PHYSIOLOGICAL Effects of G Forces (G-LOC, etc)
Physical Fatigue (Overexertion)
Fatigue – Physiological/Mental
Hypoxia
Motion Sickness
Circadian Rhythm Desynchrony
Pre-Existing Physical Illness/Injury
Prescribed Meds for Injury/Illness
Condition of
Individuals
Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States
Psycho-
Behavioral
Factors Preconditions
for
Unsafe Acts
Unsafe
Acts
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Condition of
Individuals
Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States
PHYSICAL/MENTAL LIMITS Learning Ability/Rate
Memory Ability/Lapses
Anthropometric/Biomechanical Limits
Motor Skill/Coordination or Timing
Deficiency
Technical/Procedural Knowledge
Preconditions
for
Unsafe Acts
Unsafe
Acts
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Condition of
Individuals
Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Adverse
Physiological
States
PERCEPTUAL FACTORS Illusions: Kinesthetic/Vestibular/Visual
Misperception of Operational
Conditions
Misinterpreted/Misread Instrument
Expectancy
Auditory Cues
Spatial Disorientation: 1, 2, & 3
Temporal Distortion
Physical/
Mental
Limitations Preconditions
for
Unsafe Acts
Unsafe
Acts
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Supervision
Inadequate supervision: kurangnya bimbingan, kebijakan tertulis, atau kesempatan pelatihan
Failure to correct known problem: masalah dengan tim atau operasi
Inappropriate Operations: kurangnya penilaian risiko atau penempatan petugas yang tidak tepat
Violations: melakukan pekerjaan di luar SOP
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Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
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Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
INADEQUATE SUPERVISION Leadership/Supervision/Oversight Inadequate
Supervision – Modeling
Local Training Issues/Programs
Supervision – Policy
Supervision – Personality Conflict
Supervision – Lack of Feedback
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
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PLANNED INAPPROPRIATE
OPERATIONS Ordered/Led Mission Beyond Capability
Crew/Team/Flight Makeup/Composition
Limited Recent Experience
Limited Total Experience
Proficiency
Risk Assessment – Formal
Authorized Unnecessary Hazard
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
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FAILED TO CORRECT A
KNOWN PROBLEM Personnel Management
Operations Management
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
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SUPERVISORY VIOLATIONS Supervision – Discipline Enforcement
Supervision – Unwritten Policy
Directed Violation
Assigned Unqualified Individuals
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
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Resource/Acquisition Management: alokasi peralatan
Organizational Climate
Process: kebijakan dan prosedur yang menunjang proses operasi
Organizational Factors The Organization is responsible for overall policy, doctrine, and allocation of
resources to the subordinate units
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Organizational
Influences
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
Organizational
Climate
Resource/Acquisition
Management Organizational
Process
ORGANIZATIONAL
INFLUENCES
RESOURCE/ACQUISITION
MANAGEMENT Air Traffic Control Resources
Airfield Resources
Operator Support
Acquisition Policies/Design
Processes
Attrition Policies
Accession/Selection Policies
Personnel Resources
Information Resources/Support
Financial Resources/Support
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Organizational
Climate
ORGANIZATIONAL
INFLUENCES
ORGANIZATIONAL
INFLUENCES
Organizational
Climate
ORGANIZATIONAL
CLIMATE Unit/Organizational Values/Culture
Evaluation/Promotion/Upgrade
Perceptions of Equipment
Unit Mission/Aircraft Change
Unit Deactivation
Organizational Structure
Resource/Acquisition
Management Organizational
Process
Organizational
Influences
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
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Organizational
Climate Operational
Process
ORGANIZATIONAL
INFLUENCES
ORGANIZATIONAL
INFLUENCES
Organizational
Process
ORGANIZATIONAL
PROCESS Ops Tempo/Workload
Program and Policy Risk Assessment
Procedural Guidance/Publications
Organizational Training Issues/Programs
Doctrine
Program Oversight/Program Management
Resource/Acquisition
Management
Organizational
Influences
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
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REFERENSI
• Chris W. Johnson, Philippe Palanqu. Human Error Safety And Systems Development. 2004. Kluwer Academic Publishers, New York
• David Shinar. Traffic safety and Human Behavior. 2007.Elsevier
• Samuel G. Charlton, Thomas G. O’Brien. Handbook od Human Factors Testing and Evaluation
• George A. Peters, Barbara J. Peters. Human Error Causes and Control. 2006. Taylor & Francis Group