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