shappell and wiegmann, 1997 a failure analysis and classification system
TRANSCRIPT
Shappell and Wiegmann, 1997
A FAILURE ANALYSIS AND A FAILURE ANALYSIS AND CLASSIFICATION SYSTEMCLASSIFICATION SYSTEM
Shappell and Wiegmann, 1997
Accident & InjuryAccident & Injury
Latent Conditions
Latent Conditions
Latent Conditions
Active Conditions
Failed orAbsent Defenses
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Shappell and Wiegmann, 1997
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ViolationsErrorsErrors
ExceptionalRoutinePerceptualErrors
DecisionErrors
Skill-BasedErrors
Shappell and Wiegmann, 1997
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
DecisionErrors
DECISION ERROR Rule-based - Misapplication of a good rule - Application of a bad rule Knowledge-based - Inaccurate or incomplete
knowledge of the problem
Shappell and Wiegmann, 1997
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
Skill-BasedErrors
SKILL-BASEDERRORS
Attention Failures Memory Failure
Shappell and Wiegmann, 1997
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
PERCEPTUALERRORS
Misjudge Distance, Altitude, Airspeed Spatial Disorientation Visual Illusions
Shappell and Wiegmann, 1997
Exceptional
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ROUTINE VIOLATIONSHabitual departures
from rules condoned by management
Shappell and Wiegmann, 1997
Routine
Violations
Exceptional
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
Exceptional
Violations
Exceptional
UNSAFEACTS
UNSAFEACTS
EXCEPTIONAL VIOLATIONS Isolated departures from rules NOT condoned by management
Shappell and Wiegmann, 1997
Shappell and Wiegmann, 1997
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Preconditionsfor
Unsafe Acts
UnsafeActs
Shappell and Wiegmann, 1997
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Adverse Mental States
ADVERSE MENTAL STATE
Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation
Shappell and Wiegmann, 1997
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Adverse Physiologic
al States
ADVERSE PHYSIOLOGICALSTATES
Hypoxia Motion Sickness Medical Illness Intoxication
Shappell and Wiegmann, 1997
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Physical/Mental
Limitations
PHYSICAL/MENTALLIMITATIONS
Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude
Shappell and Wiegmann, 1997
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Interpersonal Resource
Mismanagement
INTERPERSONAL RESOURCEMISMANAGEMENT
Not Working as a Team Poor Aircrew Coordination Improper Briefing Before a Mission Inadequate Coordination of Flight
Shappell and Wiegmann, 1997
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
PERSONAL READINESSReadiness Violations
Crew Rest Requirements Bottle-to-Brief Rules Self-Medicating
Poor Judgement Poor Dietary Practices Overexertion While Off
Duty Excessive “Voluntary”
PT
Shappell and Wiegmann, 1997
Shappell and Wiegmann, 1997
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UnforeseenUnforeseen Known
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
UNSAFESUPERVISION
UNSAFESUPERVISION
Shappell and Wiegmann, 1997
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Shappell and Wiegmann, 1997
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
InadequateSupervision
UNSAFESUPERVISION
UNSAFESUPERVISION
Known
INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance
Shappell and Wiegmann, 1997
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
PlannedInappropriate
Operations
UNSAFESUPERVISION
UNSAFESUPERVISION
Known
PLANNED INAPPROPRIATEOPERATIONS
Improper Work Tempo Poor Crew Pairing
Shappell and Wiegmann, 1997
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
Failed toCorrectProblem
UNSAFESUPERVISION
UNSAFESUPERVISION
Known
FAILED TO CORRECT AKNOWN PROBLEM
Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard
Shappell and Wiegmann, 1997
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnforeseenUnforeseen Known
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
Known
SUPERVISORY VIOLATIONS Not Adhering to Rules and Regulations Willful Disregard for Authority by Supervisors
Shappell and Wiegmann, 1997
Shappell and Wiegmann, 1997
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
Shappell and Wiegmann, 1997
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
ResourceManagement
ResourceManagement
ORGANIZATIONALINFLUENCES
RESOURCE MANAGEMENT Human Monetary Equipment/Facility
Shappell and Wiegmann, 1997
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
OrganizationalClimate
ORGANIZATIONALINFLUENCES
ORGANIZATIONALCLIMATE Structure Policies Culture
Shappell and Wiegmann, 1997
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
OperationalProcess
ORGANIZATIONALINFLUENCES
OPERATIONALPROCESS Operations Procedures Oversight