Systems thinking in Ergonomics by Jayadeva de Silva
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The document discusses human factors and ergonomics, specifically how human error contributes to accidents. It introduces the Human Factors Analysis and Classification System (HFACS) framework, which views accidents as the result of active and latent failures at multiple levels, from unsafe acts of operators to latent failures in organizational processes and decision making. The framework breaks down causal factors into unsafe acts, preconditions for unsafe acts, unsafe supervision, and organizational influences. Understanding accidents through this systems perspective helps move away from blame of individuals.
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Systems thinking in Ergonomics by Jayadeva de Silva
- 1. 1 Systems Thinking in Ergonomics Jayadeva de Silva Let us start with an activity Consider a case of an Error from your personal experience • You've carefully thought out all the angles. • You've done it a thousand times. • It comes naturally to you. • You know what you're doing, its what you've been trained to do your whole life. • Nothing could possibly go wrong, right ? ……………………………………………………… ………………………………………………………… Importance of Human factors • Cost of Ignoring Human Factors is Poor Quality! • Increased probability of accidents and errors • Less spare capacity to deal with emergencies • Increased labor turnover • Lower productive output • Increases in lost time • Higher medical costs • Higher material costs • Increased absenteeism • Low quality work • Injuries, strains • Human Error and Accidents
- 2. “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997 Human Error and Accidents It is not surprising then, that human error has been implicated in 60-80% of accidents in complex systems. In fact, while accidents solely attributable to environmental and mechanical factors have been greatly reduced over the last several years, those attributable to human error continue to plague organizations. 2 • Human Error and Accidents • Why is the human blamed? – It is human nature to blame what appears to be the active operator when something goes wrong. – Our legal system is geared toward the determination of responsibility, fault, and blame. – It is easier for management to blame the worker than to accept the fact that the workplace, procedure, environment, or system needs improving. – The forms we fill out to investigate accidents are usually modeled after the unsafe act, unsafe condition dichotomy. Human Factors Analysis and Classification System (HFACS) • HFACS is based on the “Swiss Cheese” model of error by James Reason (1990) • Applied to human error analysis in aviation by – Scott Shapell, Ph.D., Civil Aeromedical Institute and – Doug Wiegmann, Ph.D., University of Illinois HFACS: Guiding Principles Example Health care • Principle 1: Health care systems are similar in nature to other complex productive systems. • Principle 2: Human errors are inevitable within such a system. • Principle 3: Blaming errors on the human is like blaming a mechanical failure on the device. • Principle 4: An accident, no matter how minor, is a failure of the system.
- 3. Principle 5: Accident investigation and error prevention go hand-in-hand 3 Breakdown of A Productive System Latent Conditions Excessive cost cutting Inadequate promotion policies Latent Conditions Deficient training program Improper crew pairing Organizational Factors Failed or Absent Defenses Copyright 2001 by Dr. Gallimore, Wright State University Active and Latent Conditions Poor team work/team resource management Loss of situational awareness Active Conditions Incorrect calculation of dosage Incorrect use of equipment Did not communicate all needed information Did not check device Department of Biomedical, Human Factors, & Industrial Engineering Inputs Economic inflation Few qualified professionals Regulations Government policies Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Adapted from Reason (1990) Accident/Injury
- 4. 4 UNSAFE ACTS Errors Perceptual Errors Copyright 2001 by Dr. Gallimore, Wright State University Violations Routine Exceptional Department of Biomedical, Human Factors, & Industrial Engineering Decision Errors Skill-Based Errors DECISION ERROR Rule-based Decisions - If X, then do Y - Highly Procedural Choice Decisions - Knowledge-based Ill-Structured Decisions - Problem solving Unsafe Acts UNSAFE ACTS Errors Perceptual Errors Copyright 2001 by Dr. Gallimore, Wright State University Violations Routine Exceptional Department of Biomedical, Human Factors, & Industrial Engineering Decision Errors Skill-Based Errors SKILL-BASED ERRORS Attention Failures - Breakdown in information scan - Inadvertent operation of control Memory Failure - Omitted item in checklist - Omitted step in procedure - Forgot to check device Unsafe Acts
- 5. 5 Copyright 2001 by Dr. Gallimore, Wright State University Department of Biomedical, Human Factors, & Industrial Engineering Decision Errors Violations Routine Exceptional Skill-Based Errors UNSAFE ACTS Perceptual Errors Errors PERCEPTUAL ERRORS Misread label Misread chart Misjudge type of auditory alarm Unsafe Acts Copyright 2001 by Dr. Gallimore, Wright State University Department of Biomedical, Human Factors, & Industrial Engineering Decision Errors Exceptional Routine UNSAFE ACTS Errors Perceptual Errors Skill-Based Errors Violations ROUTINE (INFRACTIONS) (Habitual departures from rules condoned by management) Violation of Orders/Regulations/Standard Operating Procedures -not checking ID bands -failure to confirm allergy status when ordering antibiotic in doctors office -Double check system for blood transfusion -Side bed rails not raised Failed to Adhere to policy Not Current/Qualified for procedure Improper Procedures Unsafe Acts
- 6. 6 Copyright 2001 by Dr. Gallimore, Wright State University Routine Violations Department of Biomedical, Human Factors, & Industrial Engineering Exceptional UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors EXCEPTIONAL (Isolated departures from the rules not condoned by management) Violated - Keep drugs on floor - Extending surgical procedure without patient consent Accepted Unnecessary Hazard Not Current/Qualified for Procedure Violated standard medical practice Unsafe Acts
- 7. 7 Copyright 2001 by Dr. Gallimore, Wright State University Department of Biomedical, Human Factors, & Industrial Engineering Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States ADVERSE MENTAL STATE Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS FOR UNSAFE ACTS Copyright 2001 by Dr. Gallimore, Wright State University Substandard Practices of Operators Department of Biomedical, Human Factors, & Industrial Engineering Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Conditions of Operators ADVERSE PHYSIOLOGICAL STATES Medical Illness Extreme fatigue Preconditions for Unsafe Acts Unsafe Acts
- 8. 8 Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Copyright 2001 by Dr. Gallimore, Wright State University Substandard Practices of Operators Department of Biomedical, Human Factors, & Industrial Engineering Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States PHYSICAL/MENTAL LIMITATIONS Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS FOR UNSAFE ACTS Substandard Practices of Operators Crew Resource Mismanagement CREW RESOURCE MISMANAGEMENT Copyright 2001 by Dr. Gallimore, Wright State University Department of Biomedical, Human Factors, & Industrial Engineering Personal Readiness Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Conditions of Operators Not Working as a Team Poor team Coordination Improper Briefing Before a Procedure Inadequate Coordination of materials/technologies/human resources Preconditions for Unsafe Acts Unsafe Acts
- 9. 9 PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Copyright 2001 by Dr. Gallimore, Wright State University Substandard Practices of Operators Department of Biomedical, Human Factors, & Industrial Engineering Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States PERSONAL READINESS Readiness Violations Rest Requirements Self-Medicating Poor Judgement Poor Dietary Practices Overexertion While Off Duty Preconditions for Unsafe Acts Unsafe Acts SUPERVISION Planned UNSAFE Inappropriate Operations Inadequate Supervision INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance Copyright 2001 by Dr. Gallimore, Wright State University Failed to Correct Problem Supervisory Violations Department of Biomedical, Human Factors, & Industrial Engineering Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts
- 10. 10 Inadequate Supervision SUPERVISION Planned UNSAFE Inappropriate Operations INAPPROPRIATE PRACTICES Risk without Benefit Improper Work Tempo Poor Team Pairing Copyright 2001 by Dr. Gallimore, Wright State University Failed to Correct Problem Supervisory Violations Department of Biomedical, Human Factors, & Industrial Engineering Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts
- 11. 11 Inadequate Supervision SUPERVISION Planned UNSAFE Inappropriate Operations FAILED TO CORRECT A KNOWN PROBLEM Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard Copyright 2001 by Dr. Gallimore, Wright State University Failed to Correct Problem Supervisory Violations Department of Biomedical, Human Factors, & Industrial Engineering Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision SUPERVISION Planned UNSAFE Inappropriate Operations SUPERVISORY VIOLATIONS Not Adhering to Rules and Regulations Willful Disregard for Authority by Supervisors Copyright 2001 by Dr. Gallimore, Wright State University Failed to Correct Problem Supervisory Violations Department of Biomedical, Human Factors, & Industrial Engineering Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts
- 12. 12 ORGANIZATIONAL INFLUENCES Organizational Climate Resource Management RESOURCE MANAGEMENT Human Monetary Equipment/Facility Copyright 2001 by Dr. Gallimore, Wright State University Operational Process Department of Biomedical, Human Factors, & Industrial Engineering Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts ORGANIZATIONAL INFLUENCES Organizational Climate Resource Management ORGANIZATIONAL CLIMATE Structure Policies Culture Copyright 2001 by Dr. Gallimore, Wright State University Operational Process Department of Biomedical, Human Factors, & Industrial Engineering Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts
- 13. 13 Human Factors has been Effectively Applied to a Variety of Complex Systems • Example from Aviation – Design of aircraft – Air Traffic control • Nuclear Power Plants • Manufacturing • Aerospace – Space station – Space shuttles • Anesthesiology • Computer Systems • Remotely Operated Vehicles • Automobiles What are the System Benefits • Reduction in reported incidents and accidents • Reduction in error • Improved communication • Reduced personnel requirements because tasks can be more easily accomplished • Increased customer satisfaction • More quality time with customers • Reduced job injuries • Reduced patient waiting times • Less “lost” information (forms, documents, etc) • Better handoff
- 14. 14 • Reduced workload • Increased worker job satisfaction Etc… Group Work Group Activity 1 • Prepare an outline of an answer to the following question “The Accident was the operator’s fault” Discuss this system failure with reference to the capabilities of human, their tools, and the environments in which they work Group Activity 2 • Can you think of some research topics based on the subject we discussed today • List them
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