Human Factors in Investigation: Understanding Human Error and Managing Safety

1. MINA Handbook Chapter 12: Human Factors Investigation

2. HUMAN FACTORS

3. Human Error Rates 1/ 10 1/ 100 1/ 1,000 1/ 10,000 1/ 100,000 1/ 1,000,000 1/ 1 Crew reaction to air disaster simple arithmetic upper level of human credibility “seeing” out of calibration as “in tolerance” simulated mil emergency general error of omission for items embedded in procedure general error of omission two-man team (one do): one check; than reverse roles) passive inspection • Human vary in stress resistance • Failure mode for humans vice machines • Expectations and stereotypes • Perception - Seeing things in different ways general error of commission (misread)

4. Deliberative Violation Routine Exceptional Criminal Misconduct Discipline S Y S T E M P R O B L E M S Intended Action Supervision Directing Monitoring Selection Knowledge Skills, Abilities Training Initial Recurring Procedure Published Unpublished Hardware Hazard/risk Safety Devices Warning Devices Honest Mistake Rule Based Knowledge Based Why was an unsafe act performed Lapse Memory Failure Unintended Action Skip Attentional Failure Basic Human Error Types

5. Human Performance Factors

6. Human Error Issues • Risk Taking • Knowledge and Skill • Human Relationships • Communication • Responsibility, Accountability, and Enforcement • Peer Pressure, Ego and Pride • Supervision • Training

7. Managing Human Error

8. Human Factor Issues

9. Human Factors Systems Modelof a Work Environment • Organization • Philosophy • Other • Organizations • Policies • Procedures • Selection • Continuous • Quality • Improvement • Supervision • Planning • Organizing • Prioritizing • Instructing • Instruction • Feedback • Performance • Management • Team Building • Immediate Environment • Facilities • Weather • Design/Configuration • Equipment/Tools/Parts • Written/Computer Material • Tasks • Time • Pressure • On-the-Job • Training • Worker • Knowledge • Skills • Abilities • Other

10. Human Factors in the WorkplacePhilosophy • Workers do not make errors on purpose • There are factors in the work environment that contribute to human error • Errors result from a series of related contributing factors • Most of these contributing factors result from processes that can be managed

11. Management Theories,Styles and Safety • Hierarchy of Needs • Incongruency • Expectance and Reward • Theory X and Theory Y • System 4 • The Managerial Grid

12. The SHEL Model S = Software (procedures symbology, etc) H = Hardware (machine) E = Environment L = Liveware H S L E L The match or mismatch of the blocks (interface) is just as important as the characteristics of the blocks. A mismatch can be source of human error.

13. The Individual -- “Livewire” Physical Factors Characteristics Sensory Limitations Psychological Factors Perceptions, Attention Information Processing Workload Experience Knowledge, Training Planning, Attitudes Mental State, Personality Psychosocial Factors Pressure, Conflict Financial, Family H S L E L Physiological Factors Nutritional, Health Lifestyle, Fatigue Drugs, Alcohol Incapacitation, Illusions

14. Livewire - Livewire Interface Oral Communications Visual Signs Schedulers, Controllers Team/Crew Interactions Supervision Briefings Task Assignments Co-organization Customers Behavior, Briefing Knowledge of Process, Procedures Worker - Management Personnel - Human Resources Selection, Staffing, Training Policies, Incentives, Seniority Resource allocation, Operating Pressure Supervision Quality Control, Standards Labor Relations Pressures Regulatory Agency Audit, Inspection, Monitoring H S L E L

15. Liveware - Machine (Hardware)Interface Workspace Layout, Standardization Communication equipment Eye Reference Position Vis. restrictions Ergonomics Movement Illumination Level Motor Workload Information Displays Alerting and Warnings Operation of Instruments Equipment Switches, Controls Displays Instruments location movement Colors, Markings Illumination Confusion Standardization H S L E L

16. Human - System -- “Software” Interface Automation Operator Workload Monitoring Task Task Saturation Situation Awareness Skill Maintenance Utilization Regulatory Requirements Qualifications, Certification Medical Certificate License, Non-compliance Infraction History H Written Information Manuals, Checklists, Publications Regulations Maps & Charts Instructions, SOPs, Signage Computers S L E L

17. Liveware - Environment - Interface Outside immediate work area Weather, visibility time of day Lighting/glare, other movement, wind Distractions Effects of other on-going activity Other physical conditions Immediate work area Heat, Cold Illumination, Glare Acceleration Effective of noise Vibration Air Quality, Humidity Pollution, Fumes Radiation Other Physical Conditions H S L E L

18. Organizational Culture • Shapes our perceptions of safety • Determine the relative importance placed on safety • Impacts member’s activities regarding safety • Senior management plays a big part in setting the tone: • Articulate values • Reinforcement norms

19. How Do Your Determine CurrentCulture and the Role of Management? • Focus Groups Cross section of organization • Questionnaires Attitudes: Safety practices and perceived weaknesses • Observations Checklists: on-line behaviors across work cycles • Interviews Individual and Group

20. Looking at Risk ManagementDuring an Investigation Two Views: Investigation Management: minimizing risk to the investigators Use of Risk Management: by the mishap organization

21. Minimizing Risk to theInvestigators • Investigation management includes hazard identification and risk control at the mishap site. The investigation team leader is responsible for the safety of all team members while overall safety remains with the site manager -- i.e., shop supervisor, police, OSC. • AFI 90-901 implements Air Force ORM in “any given situation” - that includes safety functions such as investigation

22. Basic Principles:The ORM 6-Step Process • Supervise • and Review • Identify • the Hazards • Risk Control • Implementation • Assess • Risks • Make • Control • Decisions • Analyze • Risk Control • Measures

23. Minimizing Risk to theInvestigators • Make a Hazard List • If you are not familiar with the organization’s process, get a supervisor to help you • If you are part of an investigation team, get the team to help you • If necessary, do a Hazard Analysis • Assess the Risks • Analyze the control measures • Use the Safety Order of Precedence • Make a decision on the control measures • Implement • Supervise and Review

24. Safety Order of Precedenceat a Mishap Site • Stop the Energy at the Mishap Site • Shield Investigators from Energy • Remove Investigators from Energy’s Path • Use Only Qualified, Trained Investigators • Provide instructions to those augmenting the investigation • Protect the Investigators with Safety Equipment, PPE

25. Absent or Failed Defenses

26. Absent or Failed Defenses

27. The Organization’s Use of Risk Management Vision: “Create an Air Force in which every leader, airman, and employee is trained and motivated to personally manage risk in all they do, on and off-duty. . . “ Monitoring: “If the risk control has been well designed, it will favorably change either physical conditions or personnel behavior during the conduct of an operation. The challenge is to determine the extent to which this change is taking place.”

28. “Every accident, not matter how minor, is a failure of (the) organization”

29. Investigator Must UnderstandConflict in Needs and Goals • The Organization creates risks • in meeting work requirements • An Organization can minimizing risk • and sometimes can eliminate risks • The Organization must make risk • decisions • BOTTOM LINE: An effective • Organization needs to identify, assess • And control risk Mission Man Management Machine Medium Time

30. General Discussion • All our operations and our daily routines involve risk • All our operations require decisions that include hazard identification, risk assessment and risk control • Effective Risk Management requires a disciplined, organized and logical thought process to make the right decisions • Significance of the mission and timeliness of the required action impact the risk decision • How much beyond the minimum risk is prudent? Ethically required?

31. Operational Risk Management • A tool for individuals, managers, risk assessment teams and safety personnel to identify hazards and make risk decisions • It’s also an investigative tool that can be used to identify the hazards and the risk decisions made by the organization prior to a mishap The Basic Investigator’s Question: How did the organization and the individual identifyhazards and then assess and control risk?

32. The Investigator andRisk Management • How much of a problem a hazard presents can’t be determined by the organization until the hazard is converted to a risk. What knowledge of the situation was available and considered before the decision was made? • When the hazard is expressed in terms of how likely it is to occur, and how serious the consequences are if it does occur…then the organization can make rational decisions about how to deal with that hazard. Did the organization consider the consequences of its decision?

33. Risk Management LogicWhat are the Hazards in the Operation? Probability? Severity? Exposure? What is the Level of Risk? Is this Level of Risk Acceptable? Yes, Continue No Can Risk be Eliminated? Yes, Take Action No Can this Risk Be Reduced/Minimized? Yes, Take Action No Cancel Operation

34. Investigating the Use ofOperational Risk Management

35. Investigating the Use ofOperational Risk Management

36. Investigating the Use ofOperational Risk Management

37. Four Rules of Risk Management 1. Accept no unnecessary risks The key word is “unnecessary.” An unnecessary risk is a risk that does not contribute meaningfully to the operation. Did the organization undertake the activity knowing the hazards and risks as well as appropriate controls? Did it, through omission or commission, accept an unnecessary risk?

38. Four Rules of Risk Management 2. Make risk decisions at the appropriate level Anyone can make a risk decision; however, the “appropriate level” for an organization’s risk decisions is the one that can allocate the resources and is accountable for the success or failure of the operation. Once that person has established acceptable level of risk, other persons involved in the activity must understand the need to elevate a risk decision when the known residual risk of an activity is at an unnecessary risk level. Given the facts of the mishap, was the risk decision made at the appropriate level?

39. Four Rules of Risk Management 3. Accept risk when the benefits outweigh the costs There is always risk, and were there is risk, application of a deliberate process to manage risk should minimize the probability of an injury or damage causing event. Risk management requires that the organization making the decision understand the cost and the benefit. That understanding is based on knowledge, experience, and mission requirements. Was a deliberate, risk management process used? What was the decision makers knowledge, experience and mission requirements? Was other knowledge and experience available and used, or not used?

40. Four Rules of Risk Management 4. Integrate Risk Management into Planning It’s easier to integrate risk management early in the life cycle of any operation (training, operations or combat). When was risk management introduced into the operation? How was risk management introduced into the operation? What resources did the organization offer and use to manage risk? Did the organization provide feedback to the process? Was risk management effective?

41. Safety Order of Precedence • Eliminate The Hazard • The preferred solution – a non-existent hazard cannot cause an accident. • Control The Hazard • The most common response • Reduce the severity of the effect or the probability of occurrence of an accident resulting from a hazard.

42. Safety Order of Precedence • Provide Alerts & Warnings • Not an engineering solution • Does nothing to control the hazard • Requires action by an individual • Establish Procedural Controls • Does not control the hazard • Remains in place without presence of a hazard. Training in Essential! • Accept Residual Risk

43. What Does This Mean for the Safety Investigator? • The investigator needs to answer questions: • How was safety designed in? • What was the analyses that identified the hazards and the design corrective actions? • Was training included for the procedural corrective actions? • Specifically could the design have contributed to the mishap under investigation? • What were the specifications and design criteria that applied when the shop or tool was new? Were they followed and maintained? • Was the acceptable risk level appropriate? • Has the mission or usage changed without a safety assessment? • Were the procedures used appropriate?