HUMAN FACTOR – Swiss Cheese Theory FAKTOR MANUSIA DALAM K3 PERTEMUAN 6 PUTRI HANDAYANI, SKM, MKKK PRODI KESMAS FIKES

  HUMAN FACTOR – Swiss Cheese Theory FAKTOR MANUSIA DALAM K3 PERTEMUAN 6 PUTRI HANDAYANI, SKM, MKKK PRODI KESMAS / FIKES

TUJUAN/CAPAIAN PEMBELAJARAN

  

Menguraikan konsep Konsep swiss cheese model, dan

Lingkup pengamatan swiss cheese model

  Reason’s “Swiss-cheese” Organizational Factors

  Model of Human Error Unsafe Supervision

  

Preconditions

for

Unsafe Acts

Unsafe

  Acts Failed or Absent Defenses

  Accident & Injury Adapted from Reason (1990) Errors ACTS Errors Perception

  Skill-Based Judgment and Violations Inadequate

  Supervision Planned Inappropriate Operations

  Failed to Correct Known Problem Supervisory

  Violations SUPERVISION Management Climate Process

  

Condition of

Individuals

Cognitive Factors

  Technological Environment Physical Environment

  Self- Imposed Stress Coordination/

  Communication/ Planning Factors Personnel Factors

  Psycho- Behavioral Factors Environmental

  Factors

PRECONDITIONS

Perceptual Factors

  Physical/ Mental Limitations Adverse

  

Physiological

States

  Acts The act is the end result. It answers the question of, “what happened?” Skill-based Errors: kesalahan dalam tugas-tugas rutin-dilakukan Decision Errors: kesalahan dalam pemilihan tindakan untuk situasi tertentu Perception Errors: persepsi yang mengarah kepada tindakan yang tidak tepat

Violation: sengaja bertindak melawan kebijakan tertulis atau

prosedur.

  ACTS Violations Errors Judgment and Decision Skill-Based Misperception

  Errors Errors Errors Unsafe Unsafe Acts Acts ACTS Violations

  Errors Judgment and Decision Skill-Based Misperception

  Errors Errors Errors

DECISION ERRORS

• Risk Assessment – During

  Unsafe Operation Acts

• Task Misprioritization Necessary Action – Rushed Necessary Action – Delayed Caution/Warning
• – Ignored Wrong choice of action
ACTS Violations

  Errors Judgment and Decision Skill-Based Misperception

  Errors Errors Errors

SKILL-BASED ERRORS

• Inadvertent Operation

  Unsafe

• Checklist Error

  Acts

• Procedural Error Overcontrol/Undercontrol
• Breakdown in Visual Scan Inadequate Anti-G Straining Maneuver

ACTS Violations

  Errors Misperception

  Judgment and Decision Skill-Based Errors

  Errors Errors

  MISPERCEPTION ERRORS

(due to)

Unsafe Acts

• Misjudge Distance, Altitude, Airspeed  Spatial Disorientation  Visual Illusions

  ACTS Violations

  Errors Misperception Errors

  Judgment and Decision Errors

  Skill-Based Errors

  VIOLATIONS

  (Willful disregard for rules and instructions!)

• Violation
• – Work-around
• Violation
• – Routine/Widespread
• Violation
• – Extreme

  Unsafe Acts

  Physical environment: lingkungan kerja. Hujan, gelap, dingin, panas, dll Technological Environment: alat yang digunakan dalam misi. Desain kendaraan dan kegunaan dari sistem yang terkait Self-imposed stress: alkohol, kurang tidur, tingkat kebugaran

  

Prakondisi adalah hal-hal yang memungkinkan tindakan tidak aman terjadi,

dan mereka menjawab pertanyaan, "Mengapa hal itu bisa terjadi?" Kategorinya adalah:

  Preconditions Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Cognitive Psycho- Adverse Physical/ Perceptual Physiological Factors Factors Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts Unsafe

  Acts

  Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Psycho- Adverse Physical/ Perceptual Physiological Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts

PHYSICAL ENVIRONMENT

• Icing/Fog/Etc. on windows

  Unsafe

• Meteorological Conditions

  Acts

• Dust/Smoke/Etc. in Workspace Brownout/Whiteout
• Thermal Stress: Cold/Hot
• Maneuvering Forces In-Flight
• Noise Interference

Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Psycho- Adverse Physical/ Perceptual Physiological Factors Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts

  TECHNOLOGICAL ENVIRONMENT Unsafe

• Seating and Restraints

  Acts

• Instrument and Sensory Feedback Visibility Restrictions Controls and Switches Automation
• Personal Equipment Interference Communications - Equipment

Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Psycho- Adverse Physical/ Perceptual Physiological Factors Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts

COORD/COMM/PLAN

• Crew/Team Leadership

  Unsafe Acts

• Cross-Monitoring Performance Task Delegation Rank/Position Authority Gradient Communicating Critical Info Standard/Proper Terminology Mission Planning/Briefing
• Miscommunication

Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Psycho- Adverse Physical/ Perceptual Physiological Factors Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts

SELF-IMPOSED STRESS

  Unsafe

• Alcohol

  Acts

• Physical Fitness Drugs/Supplements/Self Medication Nutrition
• Inadequate Rest Unreported Disqualifying Medical Condition

Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Psycho- Adverse Physical/ Perceptual Physiological Factors Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts

COGNITIVE FACTORS

  Unsafe Acts

• Inattention
• Channelized Attention Cognitive Task Oversaturation Confusion
• Negative Transfer Distraction
• Geographic Misorientation (Lost)

Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Psycho- Adverse Physical/ Perceptual Physiological Factors Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts

  PSYCHO-BEHAVIORAL Unsafe Acts

• Personality Style Pre-Existing Personality Disorder Pre-Existing Psychological Disorder Emotional State Overconfidence
• Complacency
• Get-Home-Itis/Get-There-Itis
• Overaggressive

Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Adverse Physical/ Perceptual Psycho- Physiological Factors

  Mental Factors Behavioral States Limitations

  Preconditions Factors for Unsafe Acts Unsafe

ADVERSE PHYSIOLOGICAL

  Acts

• Effects of G Forces (G-LOC, etc)
• Physical Fatigue (Overexertion)
• Fatigue
• – Physiological/Mental
>Hypoxia
• Motion Sickness Circadian Rhythm Desynchrony Pre-Existing Physical Illness/Injury

Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Psycho- Adverse Physical/ Perceptual Physiological Factors Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts Unsafe

PHYSICAL/MENTAL LIMITS

  Acts

• Learning Ability/Rate
• Memory Ability/Lapses
• Anthropometric/Biomechanical Limits Motor Skill/Coordination or Timing Deficiency Technical/Procedural Knowledge

Environmental Personnel Factors Factors Physical Technological

  Coordination/ Self- Condition of Environment Environment

  Communication/ Imposed Individuals Planning Factors Stress

  Cognitive Psycho- Adverse Physical/ Perceptual Physiological Factors Behavioral Mental Factors Factors States Limitations

  Preconditions for Unsafe Acts Unsafe

PERCEPTUAL FACTORS

  Acts

• Illusions: Kinesthetic/Vestibular/Visual
• Misperception of Operational Conditions Misinterpreted/Misread Instrument Expectancy
• Auditory Cues Spatial Disorientation: 1, 2, & 3

  Supervision

Inadequate supervision: kurangnya bimbingan, kebijakan tertulis,

atau kesempatan pelatihan

  Failure to correct known problem: masalah dengan tim atau operasi

Inappropriate Operations: kurangnya penilaian risiko atau

penempatan petugas yang tidak tepat

  Violations: melakukan pekerjaan di luar SOP

  Inadequate Supervision

  Planned Inappropriate Operations

  Failed to Correct Known Problem

  Supervisory Violations

  SUPERVISION

  Unsafe Supervision Preconditions for Unsafe Acts Unsafe

  Acts

  SUPERVISION Planned Failed to

  Supervisory Inadequate

  Inappropriate Correct Known Supervision

  Violations Operations Problem

  Unsafe Supervision

INADEQUATE SUPERVISION

• Leadership/Supervision/Oversight Inadequate Supervision

  Preconditions – Modeling for

• Local Training Issues/Programs

  Unsafe Acts

• Supervision
• – Policy Supervision
• – Personality Conflict

  Unsafe

• Supervision
• – Lack of Feedback

  Acts

  SUPERVISION Planned Failed to

  Supervisory Inadequate

  Inappropriate Correct Known Supervision

  Violations Operations Problem

  Unsafe Supervision PLANNED INAPPROPRIATE OPERATIONS

• Ordered/Led Mission Beyond Capability

  Preconditions

• Crew/Team/Flight Makeup/Composition

  for Unsafe Acts

• Limited Recent Experience Limited Total Experience

  Unsafe

• Proficiency

  Acts

• Risk Assessment – Formal Authorized Unnecessary Hazard

Unsafe Supervision Preconditions for Unsafe Acts Unsafe

  Acts

  FAILED TO CORRECT A KNOWN PROBLEM

• Personnel Management Operations Management Inadequate Supervision Planned Inappropriate Operations Failed to Correct Known Problem Supervisory Violations SUPERVISION

  SUPERVISION Planned Failed to

  Supervisory Inadequate

  Inappropriate Correct Known Supervision

  Violations Operations Problem

  Unsafe Supervision

SUPERVISORY VIOLATIONS

• Supervision
• – Discipline Enforcement

  Preconditions for

• Supervision
• – Unwritten Policy

  Unsafe Acts

• Directed Violation Assigned Unqualified Individuals

  Unsafe Acts

  Organizational Factors The Organization is responsible for overall policy, doctrine, and allocation of resources to the subordinate units

  Resource/Acquisition Management: alokasi peralatan Organizational Climate Process: kebijakan dan prosedur yang menunjang proses operasi

  INFLUENCES Resource/Acquisition

  Organizational Organizational

  Management Climate

  Process

  Organizational

RESOURCE/ACQUISITION

  Influences

MANAGEMENT

  Unsafe

• Air Traffic Control Resources

  Supervision

• Airfield Resources Operator Support

  Preconditions

• Acquisition Policies/Design

  for

  Processes

  Unsafe Acts

• Attrition Policies Accession/Selection Policies

  Unsafe Acts

• Personnel Resources Information Resources/Support
• Financial Resources/Support

  INFLUENCES Resource/Acquisition

  INFLUENCES

  Organizational Organizational Organizational

  Management Climate Climate

  Process

  Organizational ORGANIZATIONAL

  Influences CLIMATE

  Unsafe Unit/Organizational Values/Culture Supervision

• Evaluation/Promotion/Upgrade
• Perceptions of Equipment Unit Mission/Aircraft Change

  Preconditions for

• Unit Deactivation

  Unsafe Acts

• Organizational Structure

  Unsafe Acts

  INFLUENCES Resource/Acquisition

  INFLUENCES

  Organizational Operational Organizational

  Management Climate

  Process Process

  Organizational Influences ORGANIZATIONAL PROCESS

  Unsafe

• Ops Tempo/Workload

  Supervision

• Program and Policy Risk Assessment Procedural Guidance/Publications

  Preconditions

• Organizational Training Issues/Programs

  for Unsafe Acts

• Doctrine
• Program Oversight/Program Management

  Unsafe Acts