Human beings by their very nature make mistakes;

therefore, it is unreasonable to expect error-free

human performance. Shappell & Wiegmann, 1997

Active versus Latent Failures (Reason, 1990)

Organizational
Factors

Latent Conditions
Budget cuts
Excess workload

Unsafe
Supervision

Latent Conditions
Deficient training program
Improper supervision

Preconditions
for
Unsafe Acts

Latent Conditions
Poor training
Mental Fatigue

Unsafe
Acts

Failed or
Absent Defenses

Active Conditions
Failed to ensure surface could hold
backhoe
Loss of situational awareness

Accident & Injury

Sunk Backhoe into mud

UNSAFE
UNSAFE
ACTS
ACTS

Violations

Errors
Errors

Decision
Errors

Unsafe
Acts

Skill-Based
Errors

Perceptual
Errors

Routine

Exceptional

UNSAFE
UNSAFE
ACTS
ACTS

Violations

Errors
Errors

Decision
Errors

Skill-Based
Errors

Perceptual
Errors

DECISION ERROR

Unsafe
Acts

Rule-based Decisions
- If X, then do Y
- Highly Procedural
Choice Decisions
- Knowledge-based
Structured Decisions
- Problem solving

Routine

Exceptional

UNSAFE
UNSAFE
ACTS
ACTS

Violations

Errors
Errors

Decision
Errors

Skill-Based
Errors

Perceptual
Errors

Routine

SKILL-BASED
ERRORS
Unsafe
Acts

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

Exceptional

UNSAFE
UNSAFE
ACTS
ACTS

Violations

Errors
Errors

Decision
Errors

Skill-Based
Errors

Perceptual
Errors

PERCEPTUAL
ERRORS

Unsafe
Acts

Misjudge Distance,
speed, weight, etc.
Loss of situational
awareness
Visual Illusions

Routine

Exceptional

UNSAFE
UNSAFE
ACTS
ACTS

Violations

Errors
Errors

Decision
Errors

Skill-Based
Errors

Perceptual
Errors

Routine

ROUTINE (INFRACTIONS)

(Habitual departures from rules condoned by management)

Unsafe
Acts

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

Exceptional

UNSAFE
UNSAFE
ACTS
ACTS

Violations

Errors
Errors

Decision
Errors

Skill-Based
Errors

Perceptual
Errors

Routine

EXCEPTIONAL

(Isolated departures from the rules not condoned

by management)
Unsafe
Acts

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

Exceptional

PRECONDITIONS
FOR
UNSAFE ACTS

Substandard
Substandard
Conditions
Conditionsof
of
Operators
Operators
Adverse
Mental
States

Preconditions
for
Unsafe Acts
Unsafe
Acts

Adverse
Physiological
States

Substandard
Substandard
Practices
Practicesof
of
Operators
Operators
Physical/
Mental
Limitations

Crew Resource
Mismanagement

Personal
Readiness

PRECONDITIONS
FOR
UNSAFE ACTS
Substandard
Substandard
Conditions
Conditionsof
of
Operators
Operators
Adverse
Mental
States

Preconditions
for
Unsafe Acts
Unsafe
Acts

Adverse
Physiological
States

Substandard
Substandard
Practices
Practicesof
of
Operators
Operators
Physical/
Mental
Limitations

Crew Resource
Mismanagement

ADVERSE MENTAL STATE

Loss of Situational Awareness

Circadian dysrhythmia
Alertness (Drowsiness)
Overconfidence
Complacency
Task Fixation

Personal
Readiness

PRECONDITIONS
FOR
UNSAFE ACTS

Substandard
Substandard
Conditions
Conditionsof
of
Operators
Operators
Adverse
Mental
States

Preconditions
for
Unsafe Acts
Unsafe
Acts

Substandard
Substandard
Practices
Practicesof
of
Operators
Operators

Adverse
Physiological
States

Physical/
Mental
Limitations

Crew Resource
Mismanagement

ADVERSE PHYSIOLOGICAL
STATES

Hypothermia
Motion Sickness
Fatigue
Medical Illness
Intoxication

Personal
Readiness

PRECONDITIONS
FOR
UNSAFE ACTS

Substandard
Substandard
Conditions
Conditionsof
of
Operators
Operators
Adverse
Mental
States

Adverse
Physiological
States

Substandard
Substandard
Practices
Practicesof
of
Operators
Operators
Physical/
Mental
Limitations

Preconditions
for
Unsafe Acts

Crew Resource
Mismanagement

PHYSICAL/MENTAL
LIMITATIONS

Unsafe
Acts

Lack of Sensory Input

Limited Reaction Time
Incompatible Physical Capabilities
Incompatible Intelligence/Aptitude

Personal
Readiness

PRECONDITIONS
FOR
UNSAFE ACTS
Substandard
Substandard
Practices
of
Substandard
Practices
of
Operators
Practices
of
Operators
Operators

Substandard
Substandard
Conditions
Conditionsof
of
Operators
Operators
Adverse
Mental
States

Adverse
Physiological
States

Physical/
Mental
Limitations

Preconditions
for
Unsafe Acts
Unsafe
Acts

Interpersonal
Resource
Mismanagement

CREW RESOURCE
MISMANAGEMENT

Not Working as a Team

Poor Coordination/Communication
Improper or No Tailgate Briefing
Inadequate Coordination of Work

Personal
Readiness

PRECONDITIONS
PRECONDITIONS
FOR
FOR
UNSAFE ATS
ACTS

Substandard
Substandard
Conditions
Conditionsof
of
Operators
Operators
Adverse
Mental
States

Preconditions
for
Unsafe Acts

Adverse
Physiological
States

Substandard
Substandard
Practices
Practicesof
of
Operators
Operators
Physical/
Mental
Limitations

Interpersonal
Resource
Mismanagement

PERSONAL READINESS

Unsafe
Acts

Readiness Problems
Inadequate Rest
Excess Alcohol Consumption
Self-Medicating
Poor Judgement
Poor Dietary Practices
Overexertion While Off
Duty
Bad Habits

Personal
Personal
Readiness
Readiness

UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Inadequate
Supervision

Unsafe
Supervision

Preconditions
for
Unsafe Acts
Unsafe
Acts

Planned
Inappropriate
Operations

Failed to
Correct
Problem

Supervisory
Violations

UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Inadequate
Supervision

Unsafe
Supervision

Planned
Inappropriate
Operations

Failed to
Correct
Problem

INADEQUATE SUPERVISION
Failure to Administer Proper Training
Lack of Professional Guidance

Preconditions
for
Unsafe Acts
Unsafe
Acts

Supervisory
Violations

UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Inadequate
Supervision

Unsafe
Supervision

Planned
Planned
Inappropriate
Inappropriate
Operations

Failed to
Correct
Problem

PLANNED
INAPPROPRIATE
Risk OPERATIONS
without Benefit

Preconditions
for
Unsafe Acts
Unsafe
Acts

No Risk Assessment
Improper Work Tempo
Poor Crew Pairing

Supervisory
Violations

UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Inadequate
Supervision

Unsafe
Supervision

Planned
Inappropriate
Operations

Failed to
Correct
Problem

Supervisory
Violations

FAILED TO CORRECT A
KNOWN PROBLEM

Failure to Correct Inappropriate Behavior

Failure to Correct a Safety Hazard
Failure to Enforce Safety Rules

Preconditions
for
Unsafe Acts
Unsafe
Acts

UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Inadequate
Supervision

Unsafe
Supervision

Planned
Inappropriate
Operations

Failed to
Correct
Problem

Supervisory
Violations

SUPERVISORY VIOLATIONS

Preconditions
for
Unsafe Acts
Unsafe
Acts

Not Adhering to Rules and Regulations

Willful Disregard for Authority by
Supervisors
Failure to Conduct Risk Assessment

ORGANIZATIONAL
INFLUENCES

Resource
Resource
Management
Management

Organizational
Climate

Organizational
Influences
Unsafe
Supervision

Preconditions
for
Unsafe Acts
Unsafe
Acts

Operational
Process

ORGANIZATIONAL
INFLUENCES

Resource
Resource
Management
Management

Organizational
Climate

Organizational
Influences

RESOURCE MANAGEMENT
Human
Budget
Equipment/Facility

Unsafe
Supervision

Preconditions
for
Unsafe Acts
Unsafe
Acts

Operational
Process

ORGANIZATIONAL
INFLUENCES

Resource
Resource
Management
Management

Organizational
Climate

ORGANIZATIONAL
CLIMATE

Organizational
Influences

Structure
Policies
Culture

Unsafe
Supervision

Preconditions
for
Unsafe Acts
Unsafe
Acts

Operational
Process

ORGANIZATIONAL
INFLUENCES

Resource
Resource
Management
Management

Organizational
Climate

Organizational
Influences

OPERATIONAL
PROCESS

Unsafe
Supervision

Operations
Procedures
Oversight

Preconditions
for
Unsafe Acts
Unsafe
Acts

Operational
Process

ORGANIZATIONAL
INFLUENCES
Resource
Management

Organizational
Climate

Organizational
Process

UNSAFE
SUPERVISION
Planned
Inappropriate
Operations

Inadequate
Supervision

Failed to
Correct
Problem

Supervisory
Violations

PRECONDITIONS
FOR
UNSAFE ACTS
Substandard
Practices of
Operators

Substandard
Conditions of
Operators
Adverse
Mental States

Adverse
Physiological
States

Physical/
Mental
Limitations

Interpersonal
Resource
Mismanagement

Personal
Readiness

UNSAFE
ACTS
Errors
Decision
Errors

Skill-Based
Errors

Violations
Perceptual
Errors

Routine

Exceptional

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