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Organizational/
Administrative
Human/
Crew
Technology/
Engineering
DDeecciissiioonn
EErrrroorrss
SSkkiillll-based
EErrrroorrss
PPeerrcceeppttuuaall
EErrrroorrss
Task/
Mission
VViioollaattiioonnss
Operational/
Physical
Environment
Acceptability
Figure 6. The Human Factors Intervention matriX
(HFIX) in three dimensions.
Once the need for specific interventions has been identified
and the feasibility of each has been assessed, the next step is
to identify providers for these intervention programs.
Unfortunately, in our experience we have seen too many
organizations simply purchase “off the shelf” intervention
packages that look good on the surface but have no
scientific support to show that they actually work. Another
common problem is that many vendors of human factors
programs have little or no real expertise in human factors or
the safety programs that they are selling. Rather, many are
former operators whose only credentials are that they have
attended human factors training as part of the their
previous job. Worse yet, some are simply retired program
managers who possess little, if any, knowledge of the
content of the various human factors programs they
managed. In the end, many vendors simply download
materials off the web, modify them for a particular domain,
and then market their wares as unique programs or
panaceas for all that ails the unsuspecting organization.
This is not to say that effective human factors safety
programs don’t exist. They do! However, to get your
money’s worth, you need to consult with recognized experts
in the field rather than contracting with some potential
charlatan whose only claim to fame is that he has been
involved in safety for twenty years. The latter may have an
Human Factors Intervention Programs
HFIX Human Factors Intervention matriX
®
Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 5
Copyright Error Management Solutions, LLC 2004
abundance of good “war stories” to tell, but it is only the
former who can really help you address your problems and
successfully apply the tools to complete the system safety
loop.
The systematic application of HFACS to the analysis of
human errors, coupled with the methodical utilization of
HFIX to generate intervention solutions, finally ensures
that an organization’s limited personnel and monetary
resources are utilized wisely. This occurs because such
efforts are needs-based and data-driven. They therefore
permit the completion of the system safety process, as
illustrated in Figure 7. Ultimately, this allows for the true
effectiveness of intervention programs to be objectively and
impartially evaluated so that they can be either modified or
reinforced to improve system performance.
Seerrvviicceess Scciieenccee
Hazard
Identification
Hazard
Assessment
Identify
Interventions
Intervention
Assessment
Intervention
Implementation
Data
Safety Management Process
HFIX
Generate Targeted
Interventions
Feasibility
Prioritize
IIddeennttiiffyy//DDeevveelloopp
HF Programs HF Consulting
Monitor
HFACS
FFiieelldd TTooooll
IInnvveessttiiggaattoorr TTrrnngg
HHFFAACCSS AAnnaallyyssiiss
IIddeennttiiffyy
Vulnerabilities
Figure 7. Human Factors in Safety Management
Systems.
CONCLUSION
Managing human error is fundamental to the viability and
profitability of any organization. However, the traditional
system safety approach has not been effective at reducing
errors in most complex systems. Innovative tools are
required that can turn errors into information, information
into knowledge, and knowledge into effective error
management solutions. Such tools are now finally available
and can help effectively integrate human factors into
traditional safety management systems. Managing human
error, which was once considered beyond the reach of
safety professionals, has now been made possible through
the scientific efforts of the founders of “Error Management
Solutions, LLC.”
Shappell, S.A. & Wiegmann, D.A. (2001). Applying Reason:
The Human Factors Analysis and Classification System
(HFACS). Human Factors and Aerospace Safety, 1(1), 59-86.
Wiegmann, D. A. & Shappell, S.A. (2001). Human error
analysis of commercial aviation accidents: Application of
the Human Factors Analysis and Classification System
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航空翻译 www.aviation.cn
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