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

HazardAssessment

IdentifyInterventions


InterventionAssessment


InterventionImplementation


DataData

Mon

itor

Mon

itor

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

HazardAssessment







DataData

Mon

itor

Mon

itor








HazardAssessment

HazardAssessment







DataData

Mon

itor

Mon

itor









HazardAssessment

HazardAssessment







DataData

Pret

end

to M

onito

rPr

eten

d to

Mon

itor







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

0

10

20

30

40

50

60

70

80

91 92 93 94 95 96 97Fiscal Year

Perc

enta

g e

U.S. Air Force Mean

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

Flight DataRecorders

Engineers Pilots

Flight DocsAdministrators

AccountabilityEnforce the

Rules

IncreaseSupervision

Counsel the “rogue” pilot

AwarenessTraining

Better PilotSelection

Change theRules

Get rid of the“bad apples”

Professionalism

LimitAutonomy

Automate the Pilot out of Loop

GPWS

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

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

GPWS

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

Detachment Mentality (SH-60)

Training in Restricted Areas

Only

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

0

10

20

30

40

50

60

70

80

91 92 93 94 95 96 97 98 99Fiscal Year

Perc

enta

g e

Previous U.S. Navy/Marine Corps Mean

00


0

10

20

30

40

50

60

70

80

90

100

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

Perc

enta

g e

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)

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

0

10

20

30

40

50

60

70

80

90

100

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

Perc

enta

g e

Previous Trend


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

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

HazardAssessment







DataData

Pret

end

to M

onito

rPr

eten

d to

Mon

itor

Safety Management ProcessSafety Management Process ScienceScienceServicesServices

Field ToolField ToolInvestigator TrngInvestigator Trng

HFACS AnalysisHFACS Analysis

IdentifyIdentifyVulnerabilitiesVulnerabilities


®



HazardAssessment

HazardAssessment







DataData

Pret

end

to M

onito

rPr

eten

d to

Mon

itor


Focus Groups

FeasibilityPrioritize





®

Human Factors Intervention matriXHFIX ®



HazardAssessment

HazardAssessment







DataData

Pret

end

to M

onito

rPr

eten

d to

Mon

itor


Identify/DevelopIdentify/DevelopHF ProgramsHF Programs HF ConsultingHF Consulting

Focus Groups






®




HazardAssessment

HazardAssessment







DataData

Mon

itor

Mon

itor


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...

Documents