a data-driven approach to managing human factors … · a data-driven approach to managing human...

A DataA Data--Driven Approach to ManagingDriven Approach to ManagingHuman Factors within the Mining IndustryHuman Factors within the Mining Industry

Scott A. Shappell, Ph.D.ProfessorClemson UniversityDepartment of Industrial Engineering

Engineering Tools and TechniquesEngineering Tools and Techniques

HazardIdentification

HazardAssessment

IdentifyInterventions

InterventionAssessment

InterventionImplementation

DataData

Safety Management ProcessSafety Management Process

Proven tools and techniques -Interventions are needs-based and data-driven

Engineering data is available to evaluate interventions before implementation

Accidents, Incidents, FOQA data, Service Reports, Modeling Data

Organized databases. Sophisticated and effective tools for analyzing data

Human FactorsHuman Factors

HazardAssessment

DataData

HazardAssessment

DataData

HazardAssessment

DataData

HazardAssessment

DataData

HazardAssessment

DataData

InputsInputs

Adapted from Reason (1990)

Accident & InjuryAccident & Injury

“Swiss-cheese” Model of Human Error“Swiss-cheese” Model of Human Error

OrganizationalFactors

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Failed orFailed orAbsent DefensesAbsent Defenses

Human Factors Analysis and Classification System

Unsafe Unsafe \\InappropriateInappropriate

ActsActs

Routine Exceptional

ViolationsViolationsErrorsErrors

DecisionErrors

Skill-basedErrors

PerceptualErrors

Unsafe / Unsafe / InappropriateInappropriate

ActsActs

Routine Exceptional

DecisionErrors

Skill-basedErrors

PerceptualErrors

DECISION ERRORS

Rule-based DecisionsChoice DecisionsIll-Structured Decisions

ActsActs

Routine Exceptional

DecisionErrors

Skill-basedErrors

PerceptualErrors

SKILL-BASED ERRORS

Attention FailuresMemory FailuresTechnique Errors

ActsActs

Routine Exceptional

DecisionErrors

Skill-basedErrors

PerceptualErrors

PERCEPTUAL ERRORS

MisperceptionsMisjudgments

ActsActs

Routine Exceptional

DecisionErrors

Skill-basedErrors

PerceptualErrors

ROUTINE VIOLATIONS(Habitual departures from rules condoned by management)

Violated training rulesFailed to comply with departmental manualsViolation of orders, regulations, and/or SOPs

Unsafe /Unsafe /InappropriateInappropriate

ActsActs

Routine Exceptional

DecisionErrors

Skill-basedErrors

PerceptualErrors

EXCEPTIONAL VIOLATIONS(Isolated departures from the rules not condoned by management)

Performed unauthorized operationAccepted unauthorized hazardNot current/qualified

PreconditionsPreconditionsfor Unsafe Actsfor Unsafe Acts

CommunicationCoordination& Planning

Fitness forDuty

Personal/Personal/InterpersonalInterpersonal

FactorsFactors

Condition ofCondition ofEmployeesEmployees

AdverseMental States

AdversePhysiological

States

Physical/Mental

Limitations

PhysicalEnvironment

TechnologicalEnvironment

EnvironmentalEnvironmentalFactorsFactors

Fitness forDuty

FactorsFactors

States

Physical/Mental

Limitations

PhysicalEnvironment

ADVERSE MENTAL STATESComplacencyStressOverconfidenceMental fatigueDistractionConfusion

Fitness forDuty

FactorsFactors

States

Physical/Mental

Limitations

PhysicalEnvironment

ADVERSE PHYSIOLOGICAL STATES

Physical fatigueSpatial disorientationVisual IllusionsHypoxiaMedical illness

Fitness forDuty

FactorsFactors

States

Physical/Mental

Limitations

PhysicalEnvironment

PHYSICAL/MENTAL LIMITATIONS

Visual limitationsHearing limitationNot current/qualifiedIncompatible physical capabilityIncompatible intelligence/aptitude

Fitness forDuty

FactorsFactors

States

Physical/Mental

Limitations

PhysicalEnvironment

CommunicationCoordination & Planning

Failed to conduct adequate briefLack of teamworkPoor communication/coordinationFailure of leadership

Fitness forDuty

FactorsFactors

States

Physical/Mental

Limitations

PhysicalEnvironment

PERSONAL READINESSCrew Rest RequirementsBottle-to-Brief RulesSelf-MedicatingPoor Dietary PracticeOverexertion While Off DutyInadequate preparation/skill

Fitness forDuty

FactorsFactors

States

Physical/Mental

Limitations

PhysicalEnvironment

PHYSICAL ENVIRONMENTWeatherLightingNoiseHeatVibration

Fitness forDuty

FactorsFactors

States

Physical/Mental

Limitations

PhysicalEnvironment

TECHNOLOGICAL ENVIRONMENT

Equipment and controlsAutomation reliability/complexityTask and Procedure DesignManuals and Checklist DesignInterfaces and Displays

SupervisionSupervision

SupervisoryViolations

InadequateSupervision

PlannedInappropriate

Activities

Failed toCorrectProblem

Activities

INADEQUATE SUPERVISIONFailure to Administer Proper TrainingLack of Professional GuidanceFailure to Provide Oversight

Activities

PLANNED INAPPROPRIATEACTIVITIES

Risk outweighs benefitsExcessive tasking/workloadPoor Crew Pairing

Activities

FAILED TO CORRECT AKNOWN PROBLEM

Failure to Correct Inappropriate BehaviorFailure to Correct a Safety Hazard

Activities

SUPERVISORY VIOLATIONSFailed to enforce the rulesAuthorized unnecessary hazardAuthorized unqualified crew for flight

OrganizationalOrganizationalInfluencesInfluences

ResourceManagement

OrganizationalClimate

OperationalProcess

ResourceManagement

OperationalProcess

RESOURCE MANAGEMENTHumanMonetaryEquipment/Facility

ResourceManagement

OperationalProcess

ORGANIZATIONAL CLIMATEStructurePoliciesCulture

ResourceManagement

OperationalProcess

OPERATIONAL PROCESSOperationsProceduresOversight

Unsafe /Unsafe /InappropriateInappropriate

ActsActs

Routine Exceptional

DecisionErrors

Skill-basedErrors

PerceptualErrors

CRM/Interpersonal

Factors

PersonalReadiness

FactorsFactors

States

Physical/Mental

Limitations

PhysicalEnvironment

Activities

ResourceManagement

OperationalProcess

U.S. NAVY/MARINE CORPSU.S. NAVY/MARINE CORPS

AVIATION ACCIDENT DATAAVIATION ACCIDENT DATA

USN/USMCMethodologyUSN/USMCUSN/USMCMethodologyMethodology

Analyzed all Class A Mishaps between FY91Analyzed all Class A Mishaps between FY91--99 associated 99 associated with human error (n=178)with human error (n=178)Analyses included all human causal factors as identified in Analyses included all human causal factors as identified in the original investigation and endorsed by the Chain of the original investigation and endorsed by the Chain of CommandCommandNONO new causal factors were identifiednew causal factors were identifiedRatersRaters

2 Aerospace Psychologists2 Aerospace Psychologists2 Flight Surgeons2 Flight SurgeonsAirframe Rated Pilot/NFO Subject Matter ExpertsAirframe Rated Pilot/NFO Subject Matter Experts

Consensus ratingConsensus rating

UnsafeUnsafeActsActs

Routine Exceptional

DecisionErrors

Skill-basedErrors

PerceptualErrors

Percentage of Human Error Mishaps Associated with Violations (FY 91-97)Percentage of Human Error Mishaps Associated with Violations (FY 91-97)

U.S. Army Mean

U.S. Navy/Marine Corps Mean

91 92 93 94 95 96 97Fiscal Year

U.S. Air Force Mean

OK Doc, Go Fix It!OK Doc, Go Fix It!

Flight DataRecorders

Engineers Pilots

Flight DocsAdministrators

AccountabilityEnforce the

IncreaseSupervision

Counsel the “rogue” pilot

AwarenessTraining

Better PilotSelection

Change theRules

Get rid of the“bad apples”

Professionalism

LimitAutonomy

Automate the Pilot out of Loop

WeatherDisplays

CockpitCameras

Violations

UnsafeActs

Routine Exceptional

ViolationsErrors

DecisionErrors

Skill-basedErrors

PerceptualErrors

Crew ResourceCrew ResourceManagementManagement

PersonalPersonalReadinessReadiness

PersonnelPersonnelFactorsFactors

Condition ofCondition ofOperatorsOperators

AdverseAdverseMental StatesMental States

AdverseAdversePhysiologicalPhysiological

StatesStates

Physical/Physical/MentalMental

LimitationsLimitations

PhysicalPhysicalEnvironmentEnvironment

TechnologicalTechnologicalEnvironmentEnvironment

UnsafeUnsafeSupervisionSupervision

SupervisorySupervisoryViolationsViolations

InadequateInadequateSupervisionSupervision

PlannedPlannedInappropriateInappropriate

OperationsOperations

Failed toFailed toCorrectCorrectProblemProblem

ResourceResourceManagementManagement

OrganizationalOrganizationalClimateClimate

OperationalOperationalProcessProcess

Environment (Hazard) -CenteredTechnology-CenteredTask-CenteredHuman-CenteredAdministrative/Org-Centered

DecisionDecisionErrorsErrors

SkillSkill--basedbasedErrorsErrors

PerceptualPerceptualErrorsErrors

ViolationsViolations

Organizational/ Organizational/ AdministrativeAdministrative

Human/ Human/ CrewCrew

Technology/ Technology/ EngineeringEngineering

Task/ Task/ MissionMission

Operational/Operational/Physical Physical

EnvironmentEnvironment

Enforcement

Limit Autonomy

Pilot Selection

Counseling

Synthetic Vision

Weather Displays

Cockpit Cameras

Flight Data RecordersAwareness Training

Accountability

Increase Supervision

Need for Low-level Flight (EA-6B)

Detachment Mentality (SH-60)

Training in Restricted Areas

Procedures for Fuel Dumping/Burn

Human Factors Intervention matriXHFIX

Initial Intervention StrategyInitial Intervention Strategy

ProfessionalismProfessionalismAccountabilityAccountabilityEnforcing the RulesEnforcing the RulesDetachment SupervisionDetachment Supervision

Tracking Human Factors Intervention StrategiesTracking Human Factors Intervention Strategies

Data-drivenIntervention

91 92 93 94 95 96 97 98 99Fiscal Year

Previous U.S. Navy/Marine Corps Mean

91 92 93 94 95 96 97 98 99 00Fiscal Year

Previous Trend

Interventions• Focus on tactical decision-making• Improved procedure development• Scenario-based training• Approach Magazine – Increased

awareness

Percentage of Human Error Mishaps Associated withDecision Errors (FY 91-00)

91 92 93 94 95 96 97 98 99 00 01 02 03Fiscal Year

Previous Trend

Percentage of Human Error Mishaps Associated withSkill-based Errors (FY 91-03)

Interventions:• Improve instrument scan• Prioritizing attention• Recognizing extremis situations• Refine basic flight skills (Stick-and-Rudder)• Practice procedures• Review the mishap database!

HazardAssessment

DataData

Safety Management ProcessSafety Management Process ScienceScienceServicesServices

Field ToolField ToolInvestigator TrngInvestigator Trng

HFACS AnalysisHFACS Analysis

IdentifyIdentifyVulnerabilitiesVulnerabilities

HazardAssessment

DataData

Focus Groups

FeasibilityPrioritize

Human Factors Intervention matriXHFIX ®

HazardAssessment

DataData

Focus Groups

HazardAssessment

DataData

Identify/DevelopIdentify/DevelopHF ProgramsHF Programs HF ConsultingHF Consulting

Focus Groups

HazardAssessment

DataData

Identify/DevelopIdentify/DevelopHF ProgramsHF Programs HF ConsultingHF Consulting

Focus Groups

Royal Netherlands Air Force

Indian Air Force

Canadian Air ForceCanadian Air Force

a data-driven approach to managing human factors … · a data-driven approach to managing human...

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