“Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.”

1. “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

3. Organizational Factors Active versus Latent Failures (Reason, 1990) • Latent Conditions • Budget cuts • Excess workload • Latent Conditions • Deficient training program • Improper supervision Unsafe Supervision • Latent Conditions • Poor training • Mental Fatigue Preconditions for Unsafe Acts • Active Conditions • Failed to ensure surface could hold backhoe • Loss of situational awareness Unsafe Acts Failed or Absent Defenses • Accident & Injury • Sunk Backhoe into mud

4. Errors Violations Perceptual Errors Decision Errors Skill-Based Errors Routine Exceptional UNSAFE ACTS Unsafe Acts

5. UNSAFE ACTS Errors Decision Errors Decision Errors DECISION ERROR Unsafe Acts UNSAFE ACTS Errors Violations Perceptual Errors Skill-Based Errors Routine Exceptional • Rule-based Decisions • - If X, then do Y • - Highly Procedural • Choice Decisions • - Knowledge-based • Structured Decisions • - Problem solving

6. UNSAFE ACTS Errors Decision Errors Skill-Based Errors Skill-Based Errors SKILL-BASED ERRORS Unsafe Acts UNSAFE ACTS Errors Violations Perceptual Errors Routine Exceptional • Attention Failures - Breakdown in visual scan - Inadvertent operation of control - Failure to see and avoid • Memory Failure - Omitted item in process - Omitted step in procedure

7. UNSAFE ACTS Errors Decision Errors Skill-Based Errors Perceptual Errors PERCEPTUAL ERRORS Unsafe Acts UNSAFE ACTS Errors Violations Perceptual Errors Routine Exceptional • Misjudge Distance, speed, weight, etc. • Loss of situational awareness • Visual Illusions

8. UNSAFE ACTS UNSAFE ACTS Violations Violations Decision Errors Skill-Based Errors Routine Routine ROUTINE (INFRACTIONS) (Habitual departures from rules condoned by management) Unsafe Acts Errors Perceptual Errors Exceptional • Violation of Manuals/Policies/SOPs • - Failed to Inspect Equipment Prior to Use • - Violated Seatbelt Policy • - Failed to Comply with Tie Down Requirements • - Conducted Unauthorized Procedure with Equipment • - Did not Conduct Tailgate Safety Meeting • - Risk Assessment not Accomplished • Failed to Adhere to Briefed Requirements • Not Current/Qualified for Equipment • Improper Procedure

9. UNSAFE ACTS UNSAFE ACTS Violations Violations Decision Errors Skill-Based Errors Exceptional Exceptional EXCEPTIONAL (Isolated departures from the rules not condoned by management) Errors Perceptual Errors Routine Exceptional • Violated Manuals/Policies/SOPs - Performed Unauthorized Operation - Horseplay with Equipment - Failed to Ensure Equipment was Operational - Allowed Unauthorized Operator - Ignored Equipment Malfunction • Accepted Unnecessary Risk • Not Current/Qualified for Equipment • Exceeded Limits of Equipment Unsafe Acts

10. PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts Unsafe Acts

11. PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States ADVERSE MENTAL STATE PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts Unsafe Acts • Loss of Situational Awareness • Circadian dysrhythmia • Alertness (Drowsiness) • Overconfidence • Complacency • Task Fixation

12. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts ADVERSE PHYSIOLOGICAL STATES Unsafe Acts • Hypothermia • Motion Sickness • Fatigue • Medical Illness • Intoxication

13. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts PHYSICAL/MENTAL LIMITATIONS Unsafe Acts Physical/ Mental Limitations Preconditions for Unsafe Acts Unsafe Acts • Lack of Sensory Input • Limited Reaction Time • Incompatible Physical Capabilities • Incompatible Intelligence/Aptitude

14. Preconditions for Unsafe Acts CREW RESOURCE MISMANAGEMENT Unsafe Acts PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Substandard Conditions of Operators Substandard Practices of Operators Interpersonal Resource Mismanagement Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Preconditions for Unsafe Acts Unsafe Acts • Not Working as a Team • Poor Coordination/Communication • Improper or No Tailgate Briefing • Inadequate Coordination of Work

15. Preconditions for Unsafe Acts PERSONAL READINESS Unsafe Acts PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ATS Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Interpersonal Resource Mismanagement Personal Readiness Personal Readiness Preconditions for Unsafe Acts Readiness Problems • Inadequate Rest • Excess Alcohol Consumption • Self-Medicating Poor Judgement • Poor Dietary Practices • Overexertion While Off Duty • Bad Habits Unsafe Acts

16. Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts UNSAFE SUPERVISION

17. UNSAFE SUPERVISION UNSAFE SUPERVISION Inadequate Supervision Unsafe Supervision Unsafe Supervision INADEQUATE SUPERVISION Preconditions for Unsafe Acts Preconditions for Unsafe Acts Unsafe Acts Unsafe Acts Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision • Failure to Administer Proper Training • Lack of Professional Guidance

18. UNSAFE SUPERVISION Planned Inappropriate Operations Unsafe Supervision Unsafe Supervision PLANNED INAPPROPRIATE OPERATIONS Preconditions for Unsafe Acts Preconditions for Unsafe Acts Unsafe Acts Unsafe Acts UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision • Risk without Benefit • No Risk Assessment • Improper Work Tempo • Poor Crew Pairing

19. UNSAFE SUPERVISION Failed to Correct Problem Unsafe Supervision Unsafe Supervision FAILED TO CORRECT A KNOWN PROBLEM Preconditions for Unsafe Acts Preconditions for Unsafe Acts Unsafe Acts Unsafe Acts UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision • Failure to Correct Inappropriate Behavior • Failure to Correct a Safety Hazard • Failure to Enforce Safety Rules

20. UNSAFE SUPERVISION Supervisory Violations Supervisory Violations Unsafe Supervision Unsafe Supervision SUPERVISORY VIOLATIONS Preconditions for Unsafe Acts Preconditions for Unsafe Acts Unsafe Acts Unsafe Acts UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Inadequate Supervision • Not Adhering to Rules and Regulations • Willful Disregard for Authority by • Supervisors • Failure to Conduct Risk Assessment

21. ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Operational Process Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

22. ORGANIZATIONAL INFLUENCES ORGANIZATIONAL INFLUENCES Resource Management Resource Management Organizational Climate Operational Process RESOURCE MANAGEMENT Organizational Influences • Human • Budget • Equipment/Facility Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

23. ORGANIZATIONAL INFLUENCES ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Climate Operational Process ORGANIZATIONAL CLIMATE Organizational Influences • Structure • Policies • Culture Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

24. ORGANIZATIONAL INFLUENCES ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Operational Process Operational Process OPERATIONAL PROCESS Organizational Influences Unsafe Supervision • Operations • Procedures • Oversight Preconditions for Unsafe Acts Unsafe Acts

25. ORGANIZATIONAL INFLUENCES Organizational Climate Resource Management Organizational Process UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Interpersonal Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Adverse Mental States Personal Readiness UNSAFE ACTS Errors Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional

26. “Whenever we talk about a worker who has been killed in an accident, we should all keep one thing in mind. They...made a judgment. They believed in it so strongly that they knowingly bet their life on it. That their judgment was faulty is a tragedy,… Every instructor, supervisor, and contemporary who ever spoke to them had the opportunity to influence their judgement, so a little bit of all of us goes with every worker we lose.” --Anonymous