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Organizational Factors. Unsafe Acts. Pre-Conditions for Unsafe Acts. Unsafe Supervision. Human Factors Analysis and Classification System (HFACS). Swiss Cheese Model. Errors. Violations. Perceptual Errors. Skill-based Errors. Decision Errors. Routine. Exceptional. Unsafe

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Presentation Transcript

Organizational

Factors

Unsafe

Acts

Pre-Conditions

for

Unsafe Acts

Unsafe

Supervision

Human Factors Analysis and Classification System (HFACS)



Errors

Violations

Perceptual

Errors

Skill-based

Errors

Decision

Errors

Routine

Exceptional

Unsafe

Acts

UNSAFE

ACTS


PRECONDITIONS

FOR

UNSAFE ACTS

Substandard

Conditions of

Operators

Substandard

Practices of

Operators

Adverse

Mental States

Adverse

Physiological

States

Physical/

Mental

Limitations

Crew

Resource

Management

Non-Supervisory

Tolerance of

Unsafe Acts

Personal

Readiness

Preconditions

for

Unsafe Acts

Unsafe

Acts


Unforeseen

Known

Inadequate

Documentation/

Procedures

Failure to

Correct

Problem

Supervisory

Violations

Unrecognized

Hazardous

Operations

Inadequate

Supervision

Planned

Inappropriate

Operations

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

UNSAFE

SUPERVISION


ORGANIZATIONAL

INFLUENCES

Resource

Management

Organizational

Climate

Operational

Process

Organizational

Influences

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts


Organizational

Factors

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

Failures in your System’s Defenses

Human Factors Analysis

Provides More than just an Accident Investigation Tool

Opportunity for Pro-active Action by Management


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