Post on 23-May-2018
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
Failed or
Absent Defenses
Organizational
Factors
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
Adapted from Reason
(1990)
Accident & Injury
Reason’s “Swiss-cheese” Model of Human Error
Errors
ACTS
Errors
Perception
Errors
Skill-Based
Errors
Judgment and
Decision-Making
Errors
Violations
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
Resource/Acquisition
Management
Organizational
Climate
Organizational
Process
ORGANIZATIONAL
INFLUENCES
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
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 The act is the end result. It answers the question of, “what happened?”
ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors
Unsafe
Acts
Unsafe
Acts
DECISION ERRORS Risk Assessment – During
Operation
Task Misprioritization
Necessary Action – Rushed
Necessary Action – Delayed
Caution/Warning – Ignored
Wrong choice of action
ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors
Unsafe
Acts
SKILL-BASED ERRORS
ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors
Inadvertent Operation
Checklist Error
Procedural Error
Overcontrol/Undercontrol
Breakdown in Visual Scan
Inadequate Anti-G Straining Maneuver
Unsafe
Acts
MISPERCEPTION ERRORS
(due to) Misjudge Distance, Altitude, Airspeed
Spatial Disorientation
Visual Illusions
ACTS
Violations Errors
Misperception
Errors Judgment and Decision
Errors
Skill-Based
Errors
Unsafe
Acts
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
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
Cognitive
Factors
Preconditions
for
Unsafe Acts
Unsafe
Acts
Condition of
Individuals
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
PHYSICAL ENVIRONMENT Icing/Fog/Etc. on windows
Meteorological Conditions
Dust/Smoke/Etc. in Workspace
Brownout/Whiteout
Thermal Stress: Cold/Hot
Maneuvering Forces In-Flight
Noise Interference
Preconditions
for
Unsafe Acts
Unsafe
Acts
Cognitive
Factors
Psycho-
Behavioral
Factors
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States
Technological
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Environmental
Factors
PRECONDITIONS
TECHNOLOGICAL
ENVIRONMENT Seating and Restraints
Instrument and Sensory Feedback
Visibility Restrictions
Controls and Switches
Automation
Personal Equipment Interference
Communications - Equipment
Physical
Environment Condition of
Individuals
Preconditions
for
Unsafe Acts
Unsafe
Acts
Cognitive
Factors
Technological
Environment
Physical
Environment Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Adverse
Physiological
States
Physical/
Mental
Limitations
Perceptual
Factors
COORD/COMM/PLAN Crew/Team Leadership
Cross-Monitoring Performance
Task Delegation
Rank/Position Authority Gradient
Communicating Critical Info
Standard/Proper Terminology
Mission Planning/Briefing
Miscommunication
Condition of
Individuals
Self-
Imposed
Stress
Preconditions
for
Unsafe Acts
Unsafe
Acts
Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Psycho-
Behavioral
Factors
Environmental
Factors
PRECONDITIONS
Adverse
Physiological
States
Physical/
Mental
Limitations
Perceptual
Factors
SELF-IMPOSED STRESS
Alcohol Physical Fitness
Drugs/Supplements/Self
Medication
Nutrition
Inadequate Rest
Unreported Disqualifying Medical
Condition
Condition of
Individuals
Preconditions
for
Unsafe Acts
Unsafe
Acts
COGNITIVE FACTORS Inattention
Channelized Attention
Cognitive Task Oversaturation
Confusion
Negative Transfer
Distraction
Geographic Misorientation (Lost)
Checklist Interference
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 Preconditions
for
Unsafe Acts
Unsafe
Acts
PSYCHO-BEHAVIORAL Personality Style
Pre-Existing Personality Disorder
Pre-Existing Psychological Disorder
Emotional State
Overconfidence
Complacency
Get-Home-Itis/Get-There-Itis
Overaggressive
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 Preconditions
for
Unsafe Acts
Unsafe
Acts
ADVERSE PHYSIOLOGICAL Effects of G Forces (G-LOC, etc)
Physical Fatigue (Overexertion)
Fatigue – Physiological/Mental
Hypoxia
Motion Sickness
Circadian Rhythm Desynchrony
Pre-Existing Physical Illness/Injury
Prescribed Meds for Injury/Illness
Condition of
Individuals
Cognitive
Factors
Technological
Environment
Physical
Environment Self-
Imposed
Stress
Coordination/
Communication/
Planning Factors
Personnel
Factors
Environmental
Factors
PRECONDITIONS
Perceptual
Factors
Physical/
Mental
Limitations
Adverse
Physiological
States
Psycho-
Behavioral
Factors Preconditions
for
Unsafe Acts
Unsafe
Acts
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
PHYSICAL/MENTAL LIMITS Learning Ability/Rate
Memory Ability/Lapses
Anthropometric/Biomechanical Limits
Motor Skill/Coordination or Timing
Deficiency
Technical/Procedural Knowledge
Preconditions
for
Unsafe Acts
Unsafe
Acts
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
Adverse
Physiological
States
PERCEPTUAL FACTORS Illusions: Kinesthetic/Vestibular/Visual
Misperception of Operational
Conditions
Misinterpreted/Misread Instrument
Expectancy
Auditory Cues
Spatial Disorientation: 1, 2, & 3
Temporal Distortion
Physical/
Mental
Limitations Preconditions
for
Unsafe Acts
Unsafe
Acts
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
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
INADEQUATE SUPERVISION Leadership/Supervision/Oversight Inadequate
Supervision – Modeling
Local Training Issues/Programs
Supervision – Policy
Supervision – Personality Conflict
Supervision – Lack of Feedback
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
PLANNED INAPPROPRIATE
OPERATIONS Ordered/Led Mission Beyond Capability
Crew/Team/Flight Makeup/Composition
Limited Recent Experience
Limited Total Experience
Proficiency
Risk Assessment – Formal
Authorized Unnecessary Hazard
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
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
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
SUPERVISORY VIOLATIONS Supervision – Discipline Enforcement
Supervision – Unwritten Policy
Directed Violation
Assigned Unqualified Individuals
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct Known
Problem
Supervisory
Violations
SUPERVISION
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
Resource/Acquisition Management: alokasi peralatan
Organizational Climate
Process: kebijakan dan prosedur yang menunjang proses operasi
Organizational Factors The Organization is responsible for overall policy, doctrine, and allocation of
resources to the subordinate units
Organizational
Influences
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
Organizational
Climate
Resource/Acquisition
Management Organizational
Process
ORGANIZATIONAL
INFLUENCES
RESOURCE/ACQUISITION
MANAGEMENT Air Traffic Control Resources
Airfield Resources
Operator Support
Acquisition Policies/Design
Processes
Attrition Policies
Accession/Selection Policies
Personnel Resources
Information Resources/Support
Financial Resources/Support
Organizational
Climate
ORGANIZATIONAL
INFLUENCES
ORGANIZATIONAL
INFLUENCES
Organizational
Climate
ORGANIZATIONAL
CLIMATE Unit/Organizational Values/Culture
Evaluation/Promotion/Upgrade
Perceptions of Equipment
Unit Mission/Aircraft Change
Unit Deactivation
Organizational Structure
Resource/Acquisition
Management Organizational
Process
Organizational
Influences
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
Organizational
Climate Operational
Process
ORGANIZATIONAL
INFLUENCES
ORGANIZATIONAL
INFLUENCES
Organizational
Process
ORGANIZATIONAL
PROCESS Ops Tempo/Workload
Program and Policy Risk Assessment
Procedural Guidance/Publications
Organizational Training Issues/Programs
Doctrine
Program Oversight/Program Management
Resource/Acquisition
Management
Organizational
Influences
Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts
REFERENSI
• Chris W. Johnson, Philippe Palanqu. Human Error Safety And Systems Development. 2004. Kluwer Academic Publishers, New York
• David Shinar. Traffic safety and Human Behavior. 2007.Elsevier
• Samuel G. Charlton, Thomas G. O’Brien. Handbook od Human Factors Testing and Evaluation
• George A. Peters, Barbara J. Peters. Human Error Causes and Control. 2006. Taylor & Francis Group