jim page, 2007 chapter 12: human factors investigation mina handbook

Jim Page, 2007Jim Page, 2007

Chapter 12: Human Factors Investigation

MINA Handbook

Jim Page, 2007Jim Page, 2007 HUMAN FACTORS


Human Error Rates

simulatedmil emergency

Crew reactionto air disaster

simplearithmetic

general errorof omission

passiveinspection

1. Human vary in stress resistance2. Failure mode for humans vice machines3. Expectations and stereotypes4. Perception - Seeing things in different ways

“seeing” out ofcalibration as“in tolerance”

general errorof omission

for itemsembedded in

procedure

general error

of commission

(misread)

upper level ofhuman credibility

two-man team(one do):one check; thanreverse roles)

1/1

1/1,000,000

1/100,000

1/10,000

1/1,000

1/100

1/10


DeliberativeViolationRoutine

ExceptionalCriminal

Misconduct

Intended Action

Why was anunsafe actperformed

UnintendedAction

HonestMistake

Rule BasedKnowledge Based

LapseMemory Failure

SkipAttentional Failure

Basic HumanError Types

S YSTEM

PROBLEMS

SupervisionDirecting

Monitoring

SelectionKnowledge

Skills, Abilities

TrainingInitial

Recurring

ProcedurePublished

Unpublished

HardwareHazard/risk

Safety DevicesWarning Devices

Discipline


Human Performance Factors

• Physiological Factors

- Health/Lifestyle

- Fatigue

- Drugs, Alcohol

• Psychological Factors

- Proficiency

- Situational Awareness

- Experience/Recency

- Attention, Attitude

- Judgment & Decision-making

• Personality Factors

- Emotional State

- Behavior

- Personality Style

• Psychosocial Factors

- Peer Influences

- Personal & Community

- Communication Factors

- Operational Factors

• Physical Factors

- Visibility

- Reach

- Strength, Dexterity

- Sensory Limitations


Human Error Issues

• Risk Taking

• Knowledge and Skill

• Human Relationships

• Communication

• Responsibility, Accountability, and Enforcement

• Peer Pressure, Ego and Pride

• Supervision

• Training


Managing Human Error


Human Factor Issues

•Stress

•Fatigue

•Boring -- Tedious

•Heights

•PPE

•Energy Noise

•Training

•Worker Safety

•Public Safety

•Environmental Safety

•Habituation

•Human Capabilities

•Stereotypical Behavior

•Workload

•Job Security

•Motivation and Rewards

•Limited Work Space

Jim Page, 2007Jim Page, 2007 Human Factors Systems Modelof a Work Environment

Organization• Philosophy• Other• Organizations• Policies• Procedures• Selection• Continuous• Quality• Improvement

Supervision• Planning•Organizing•Prioritizing•Instructing•Instruction Feedback•Performance Management•Team Building

Immediate Environment•Facilities•Weather•Design/Configuration•Equipment/Tools/Parts•Written/Computer Material•Tasks•Time Pressure•On-the-Job Training

Worker•Knowledge•Skills•Abilities•Other

Jim Page, 2007Jim Page, 2007 Human Factors in the WorkplacePhilosophy

• Workers do not make errors on purpose

• There are factors in the work environment that contribute to human error

• Errors result from a series of related contributing factors

• Most of these contributing factors result from processes that can be managed

Jim Page, 2007Jim Page, 2007 Management Theories,Styles and Safety

• Hierarchy of Needs• Incongruency• Expectance and Reward• Theory X and Theory Y• System 4• The Managerial Grid


The SHEL Model

L

L

H

S E

S = Software (procedures symbology, etc)H = Hardware (machine)E = EnvironmentL = Liveware

The match or mismatchof the blocks (interface) is just as important as thecharacteristics of theblocks. A mismatch canbe source of human error.


The Individual -- “Livewire”

L

L

H

S E

Physical Factors Characteristics Sensory Limitations

Physiological Factors Nutritional, Health Lifestyle, Fatigue Drugs, Alcohol Incapacitation, Illusions

Psychological Factors Perceptions, Attention Information Processing Workload Experience Knowledge, Training Planning, Attitudes Mental State, Personality

Psychosocial Factors Pressure, Conflict Financial, Family


Livewire - Livewire Interface

L

L

H

S E

Oral Communications

Visual Signs

Schedulers, ControllersTeam/Crew Interactions Supervision Briefings Task Assignments Co-organization

Customers Behavior, Briefing Knowledge of Process, Procedures

Worker - Management Personnel - Human Resources Selection, Staffing, Training Policies, Incentives, Seniority Resource allocation, Operating Pressure Supervision Quality Control, Standards

Labor Relations

Pressures

Regulatory Agency Audit, Inspection, Monitoring

Jim Page, 2007Jim Page, 2007 Liveware - Machine (Hardware)Interface

L

L

H

S E

Equipment Switches, Controls Displays Instruments location movement Colors, Markings Illumination Confusion Standardization

Workspace Layout, Standardization Communication equipment Eye Reference Position Vis. restrictions Ergonomics MovementIllumination LevelMotor WorkloadInformation DisplaysAlerting and WarningsOperation of Instruments

Jim Page, 2007Jim Page, 2007 Human - System -- “Software” Interface

L

L

H

S E

Written Information Manuals, Checklists, Publications Regulations Maps & Charts Instructions, SOPs, Signage

Computers

Automation Operator Workload Monitoring Task Task Saturation Situation Awareness Skill Maintenance Utilization

Regulatory Requirements Qualifications, Certification Medical Certificate License, Non-compliance Infraction History


Liveware - Environment - Interface

L

L

H

S E

Immediate work area Heat, Cold Illumination, Glare Acceleration Effective of noise Vibration Air Quality, Humidity Pollution, Fumes Radiation Other Physical Conditions

Outside immediatework area Weather, visibilitytime of day Lighting/glare,other movement, wind

Distractions

Effects of other on-going activity

Other physical conditions


Organizational Culture

• Shapes our perceptions of safety

• Determine the relative importance placed on safety

• Impacts member’s activities regarding safety

• Senior management plays a big part in setting the tone:

– Articulate values

– Reinforcement norms

Jim Page, 2007Jim Page, 2007 How Do Your Determine CurrentCulture and the Role of Management?

• Focus Groups Cross section of organization

• Questionnaires Attitudes: Safety practices and

perceived weaknesses

• Observations Checklists: on-line behaviors

across work cycles

• Interviews Individual and Group

Jim Page, 2007Jim Page, 2007 Looking at Risk ManagementDuring an Investigation

Two Views:

Investigation Management: minimizing risk to the investigators

Use of Risk Management: by the mishap organization

Jim Page, 2007Jim Page, 2007 Minimizing Risk to theInvestigators

• Investigation management includes hazard identification and risk control at the mishap site. The investigation team leader is responsible for the safety of all team members while overall safety remains with the site manager -- i.e., shop supervisor, police, OSC.

• AFI 90-901 implements Air Force ORM in “any given situation” - that includes safety functions such as investigation

Jim Page, 2007Jim Page, 2007 Basic Principles:The ORM 6-Step Process

1. Identifythe Hazards

2. AssessRisks

3. AnalyzeRisk ControlMeasures

4. MakeControl

Decisions

5. Risk ControlImplementation

6. Superviseand Review

Jim Page, 2007Jim Page, 2007 Minimizing Risk to theInvestigators

• Make a Hazard List

– If you are not familiar with the organization’s process, get a supervisor to help you

– If you are part of an investigation team, get the team to help you

• If necessary, do a Hazard Analysis

• Assess the Risks

• Analyze the control measures

– Use the Safety Order of Precedence

• Make a decision on the control measures

• Implement

• Supervise and Review

Jim Page, 2007Jim Page, 2007 Safety Order of Precedenceat a Mishap Site

• Stop the Energy at the Mishap Site

• Shield Investigators from Energy

• Remove Investigators from Energy’s Path

• Use Only Qualified, Trained Investigators

– Provide instructions to those augmenting the investigation

• Protect the Investigators with Safety Equipment, PPE


Absent or Failed Defenses

Team/Individual

Actions

(Unsafe Acts)

Absent or

Failed Defenses

Incident/

Accident

Near MissInvestigator climbs external ladder to see top of 25’ tank where a worker fell.

Does not want to disturb scene and does not attempt to use fall protection.

Investigator climbs with camera in one hand.

Investigator slips on ladder rung.

Engineering Controls:

Source modification

Substitution

Process change

Isolation

Administrative Controls:

Regulations

Instructions

Training

Quality Assurance

Scheduling

PPE

Investigator falls from a height of 12’ and breaks ankle, loses 5 days of work.

Government $1,250 digital camera irreparable damaged.


Absent or Failed Defenses

Team/Individual

Actions

(Unsafe Acts)

Absent or

Failed Defenses

Incident/

Accident

Near MissEntered building with pump engine running subjecting investigation team to high noise levels;

Exposed to rotating components;

Electrical hazards;

Chemical hazards;

Life Safety Code hazards.

Engineering Controls:

Source modification

Substitution

Process change

Isolation

Administrative Controls:

Regulations

Instructions

Training

Quality Assurance

Scheduling

PPE

Team member’s clothing caught in rotating component, arm severely injured.

Possible Class B.

Jim Page, 2007Jim Page, 2007 The Organization’s Use of Risk Management

Vision:

“Create an Air Force in which every leader, airman, and employee is trained and motivated to personally manage risk in all they do, on and off-duty. . . “

Monitoring:

“If the risk control has been well designed, it will favorably change either physical conditions or personnel behavior during the conduct of an operation. The challenge is to determine the extent to which this change is taking place.”


“Every accident, not matter how minor, is a failure of (the) organization”


Man Management

Machine

Medium

•The Organization creates risksin meeting work requirements

•An Organization can minimizing riskand sometimes can eliminate risks

•The Organization must make riskdecisions

BOTTOM LINE: An effective Organization needs to identify, assess And control risk

Time

Mission

Investigator Must UnderstandConflict in Needs and Goals


General Discussion

• All our operations and our daily routines involve risk

• All our operations require decisions that include hazard identification, risk assessment and risk control

• Effective Risk Management requires a disciplined, organized and logical thought process to make the right decisions

• Significance of the mission and timeliness of the required action impact the risk decision

• How much beyond the minimum risk is prudent? Ethically required?


Operational Risk Management

• A tool for individuals, managers, risk assessment teams and safety personnel to identify hazards and make risk decisions

• It’s also an investigative tool that can be used to identify the hazards and the risk decisions made by the organization prior to a mishap

The Basic Investigator’s Question:

How did the organization and the individual identify hazards and then assess and control risk?

Jim Page, 2007Jim Page, 2007 The Investigator andRisk Management

• How much of a problem a hazard presents can’t be determined by the organization until the hazard is converted to a risk. What knowledge of the situation was available and considered before the decision was made?

• When the hazard is expressed in terms of how likely it is to occur, and how serious the consequences are if it does occur…then the organization can make rational decisions about how to deal with that hazard. Did the organization consider the consequences of its decision?

Jim Page, 2007Jim Page, 2007 Risk Management LogicWhat are the Hazards in the Operation?

Yes, Continue

NoCan this Risk Be Reduced/Minimized?

What is the Level of Risk?

Is this Level of Risk Acceptable?

NoCan Risk be Eliminated?

Yes, Take Action

Yes, Take Action NoCancel Operation

Probability? Severity? Exposure?

Jim Page, 2007Jim Page, 2007 Investigating the Use ofOperational Risk Management

• Step 1 - Identify the Hazards - What methodology was used to identify hazards? - Was a hazard ID Tool used? Was it used properly? Was it current? Did the situation change? - Did the system focus on one hazard? - Were the employee(s) involved with the hazard recognition process? - Was human error hazard taken into consideration?

• Step 2 - Assess the Risks - What risks were assessed? How were they assessed? - What information was available to assist? - Was a Risk Assessment Matrix used? - Were risks prioritized from Greatest to Least?


• Step 3 - Analyze Risk Control Measures - What risk control options were identified? - How were risk control effects determined? - Were risk control measures prioritized? - Were the affected individuals involved with risk control analysis?

• Step 4 - Make Control Decisions - Who was the control decision maker? - Did the decision maker use available information? - Was the decision made using the best estimate of the overall potential cost? - Was the control decision the best level of risk for the overall mission?


• Step 5 - Implement Risk Controls - Was it clear who would implement the risk control(s)? - Were the people impacted by the control involved with implementing it? Did they know it was a control? Did they understand the control? Did they agree with it? Did they implement it? - Was the control appropriate? - Were the risk controls sustained?

• Step 6 - Supervise and Review - Were the controls monitored to ensure they remained in place? - Was a feedback mechanism established? - Were ineffective controls corrected? Was the correction timely?


Four Rules of Risk Management

1. Accept no unnecessary risks

The key word is “unnecessary.” An unnecessary risk is a risk that does not contribute meaningfully to the operation. Did the organization undertake the activity knowing the hazards and risks as well as appropriate controls? Did it, through omission or commission, accept an unnecessary risk?



2. Make risk decisions at the appropriate level Anyone can make a risk decision; however, the

“appropriate level” for an organization’s risk decisions is the one that can allocate the resources and is accountable for the success or failure of the operation. Once that person has established acceptable level of risk, other persons involved in the activity must understand the need to elevate a risk decision when the known residual risk of an activity is at an unnecessary risk level. Given the facts of the mishap, was the risk decision made at the appropriate level?



3. Accept risk when the benefits outweigh the costs There is always risk, and were there is risk, application of

a deliberate process to manage risk should minimize the probability of an injury or damage causing event. Risk management requires that the organization making the decision understand the cost and the benefit. That understanding is based on knowledge, experience, and mission requirements. Was a deliberate, risk management process used? What was the decision makers knowledge, experience and mission requirements? Was other knowledge and experience available and used, or not used?



4. Integrate Risk Management into Planning

It’s easier to integrate risk management early in the life cycle of any operation (training, operations or combat). When was risk management introduced into the operation? How was risk management introduced into the operation? What resources did the organization offer and use to manage risk? Did the organization provide feedback to the process? Was risk management effective?


Safety Order of Precedence

• Eliminate The Hazard– The preferred solution – a non-existent hazard cannot cause an accident.

• Control The Hazard– The most common response– Reduce the severity of the effect or the probability of occurrence of an

accident resulting from a hazard.


Safety Order of Precedence

• Provide Alerts & Warnings

– Not an engineering solution

– Does nothing to control the hazard

– Requires action by an individual

• Establish Procedural Controls

– Does not control the hazard

– Remains in place without presence of a hazard. Training in Essential!

• Accept Residual Risk

Jim Page, 2007Jim Page, 2007 What Does This Mean for the Safety Investigator?

• The investigator needs to answer questions:

– How was safety designed in?

– What was the analyses that identified the hazards and the design corrective actions?

– Was training included for the procedural corrective actions?

– Specifically could the design have contributed to the mishap under investigation?

– What were the specifications and design criteria that applied when the shop or tool was new? Were they followed and maintained?

– Was the acceptable risk level appropriate?

– Has the mission or usage changed without a safety assessment?

– Were the procedures used appropriate?

jim page, 2007 chapter 12: human factors investigation mina handbook

Documents

jim page

human error slide

human error errors

human error rates

human factors systems

human error issues risk

managed slide

managerial grid slide