swiss cheese model - wildland fire leadership …€¦ · ppt file · web view · 2011-07-19swiss...

Human Factors Human Factors Analysis and Analysis and

Classification System Classification System (HFACS)(HFACS)Organizational

Factors

UnsafeSupervision

Pre-Condition

sfor

Unsafe Acts Unsafe

Acts

Swiss Cheese ModelSwiss Cheese Model

UNSAFEACTS

ViolationsErrors

ExceptionalRoutinePerceptualErrors

Skill-basedErrors

DecisionErrors

Unsafe

Acts

PRECONDITIONSFOR

UNSAFE ACTS

SubstandardConditions of

Operators

SubstandardPractices ofOperators

Preconditionsfor

Unsafe Acts

UnsafeActs

Physical/Mental

Limitations

CrewResource

ManagementPersonal

ReadinessAdverse

PhysiologicalStates

Adverse Mental States

Non-SupervisoryTolerance ofUnsafe Acts

UNSAFESUPERVISION

Unforeseen Known

UnrecognizedHazardousOperations

InadequateDocumentation/

ProceduresInadequateSupervision

PlannedInappropriate

Operations

Failure toCorrect Problem

SupervisoryViolations

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Opportunity for Pro-active Action by

Management

Human Factors Analysis

OrganizationalFactors

Preconditionsfor

Unsafe Acts

UnsafeActs

UnsafeSupervision

Failures in your System’s Defenses

Provides More than just an Accident Investigation Tool