Tailboard Talk: HROs Use Human Factors to Improve Learning Within the Organization

丹恩·卡利（Dane Carley）和克雷格·尼尔森（Craig Nelson）

An awareness of human factors began developing around the time of the工业革命。随着人类开始与机器进行更多互动，很明显，机器设计必须解释人类的互动。对航空机的开发快速发展，这种意识使人对飞机驾驶舱设计的人为因素的重点非常重视。航空工程师发现，如果重要的开关位于正确的位置，则更容易找到或更少意外撞击（当您以每小时500英里的速度穿越天空时，很重要！）。人类因素科学一直在发展，以提高生产率并提高安全性，以增长到制造，加工，工程，设计，军事和政府行业的其他领域。

机器更安全，更可靠，但事故仍然很大程度上是因为人类与机器互动，这使得人为因素成为当今事故的最大原因。因此，事故的根本原因分析中的人为因素是五个更高可靠性的组织原理中两个的关键组成部分our first article.更高的可靠性组织（HROS）努力发展一种考虑人为因素的学习文化，这种学习文化是从专注于失败和对操作敏感的原理中演变而来的。
Human beings, believe it or not, have limits. We see this often and up close in the fire service when someone tries to defy the laws of gravity by attempting stunts that end unsuccessfully. Human limits are not only physical; they are also mental. As gifted as firefighters are, we sometimes encounter situations that may overload our mental capabilities, leading to errors. Human-factors research studies how humans think, act, and react to their environment in an effort to find methods that make our jobs, equipment, and actions safer.
In our case, the discussion of human factors relates to firefighters by studying our interaction within the various dynamic fire service environments. For example, we think of driving a fire engine to an emergency as a relatively simple task because we do it often. But behaviorists studying human factors would consider the multiple tasks occurring while driving a large vehicle at high speeds: operating lights, sirens, and air horns; maneuvering through traffic; planning routes; recalling building access; and spotting the vehicle. Our senses work together to make it seemas if we are multitasking to accomplish all of these things at once; in reality, our brain is switching between the senses up to 60 times per second to give us that illusion.1行为学家认识到我们的大脑可以执行only one task at a time and use this as one perspective while studying human factors.

与其他行业的机器一样，今天的设备比以往任何时候都更安全。然而, response fatalities have remained relatively stagnant over the past 20 years because of the many human factors involved with driving, as is the case with many aspects of fire service work.We seem to create a lot of hype about making the work safer, but are we focusing our efforts in the right places? There may be more effective methods to improve safety and reduce stagnancy.

Figure 1: This figure illustrates the number of times a factor contributed to a near miss incident (National Fire Fighter Near Miss Reporting System)

Looking at firefighter near-miss statistics shows that human factors contribute to a strong majority of incidents. Based on the categories presented in the firefighter near-miss statistics in Figure 1, we believe all of the categories except for “equipment” and “other” can be directly related to human factors. Have you ever stopped to consider how these factorsare likely to affect you, your crew, your equipment, and your daily operations? These 16 root causes lead to most of the incidents in our industry, yet we focus on a multitude of symptoms of these root causes. Why do we still see the fire service behavior of not wearing a seat belt even though we have been treating the symptom by preaching about wearing a seat belt for years? Until those of us who work in the fire service begin to focus on the human factor-related causes, we will continue opening ourselves up to becoming a statistic!

Figure 2: Proportion of aviation incidents caused by machines compared to humans (Nagel, 1988).

A look at the aviation graph with many years of statistical data in Figure 2 reveals that machine causes of accidents have significantly decreased while the proportion of human causes have significantly increased. Likewise, Figure 3 illustrates the proportion of fire-service incidents caused by machines as compared to humans; however, the fire service is just beginning to collect similar data. Given the amount of information we now have available, we are generally paying very little attention to human factors, but our hats are off to the departments that are. Now when we honestly look at the root causes and theFACTthat they are largely human-factor related, we can begin to embrace these methods to improve safety and effectiveness.

Figure 3: Proportion of fire service incidents caused by humans compared to machines for three years.

The fire service lists reasons for not accepting this approach. Or，他们只是借口吗？是否有可能是由于缺乏意识，不知道收益，感到受到威胁，担心它会暴露出弱点或不知道该如何实施它的真正原因是可能引起的吗？要过渡到HRO，消防服务需要开发学习文化，从寻求这些问题的答案开始。

A HRO operates according to the five principles discussed inour first article. However, a persistent culture of learning is fundamental to the success of the five HRO principles. The principles cannot exist without a constant desire to learn and apply the gained knowledge to operations. Therefore, HROs perform root-cause analyses of incidents, which typically find that humans’ reactions to the environment in which they were operating contributed to the incident. However, the focus is不是onwhomade the errors but onwhythe person made the decisions leading to the errors. Root-cause analysis focusing on human factors often finds that organizational culture, organizational stories, and organizational structure lead to the pattern of decision making contributing to the near miss rather than an error made by a single individual,3Therefore, HROs adjust their operating environment, which includes everything from engineering controls to organizational behavior, to prevent future incidents from the same root cause. As we begin to learn from human factors, we must track our near-miss incidents to build a solid base of information for trending root causes that can then be applied in a positive learning environment. In the next article, we will look at near-miss reporting, tracking incidents, and trending data to identify root causes.

Case Study

The following case study, taken from the Firefighter Near-Miss Reporting Web site, provides a good example of human factors contributing to a near miss. Go tothe Firefighter Near Miss Reporting Web site并搜索报告10-0001136。

Event description (as described by person reporting incident).

Our engine was dispatched to a reported structure fire at a local apartment complex, with the callers reporting visible smoke and fire. On arrival, we found a three- 综合大楼中的楼层公寓楼从A/B角落展示了大火，从第一师向上延伸并通过屋顶露面。我最初的任务是扔一个24英尺的延伸梯子，该梯子很快被更换为操作发动机的洪水炮枪以快速敲击，并让我们进入受影响的公寓。

I climbed up on the truck and disconnected the deluge gun from its base, to place an extension (pipe) on it to allow for greater reach and penetration. Placing the pipe was a standard practice among our shift’s crew, and when it过去已经完成，工程师会问消防员是否准备好在向洪水造成的枪支之前准备水。在这一转变上，工程师正在代理队长，另一个车站的消防员详细驾驶。在我将洪水与底座断开连接后不久，一架水升起，把我从脚上撞倒。值得庆幸的是，我没有从发动机上掉下来，呼吁将水关闭，以便我可以将扩展名连接到底座并完成洪水枪的设置。

Lessons Learned

事件是由于诚实错误而发生的by the driver and me. I was in the habit of either calling for the deluge gun to be charged or having the engineer double check to ensure I had it set up prior to flowing water. Working with another driver who wasn’t aware of how our engine normally operated, I should have let him know that I was using the extension and would inform him when I was ready for water. Thankfully, I was only knocked down and didn’t suffer any injuries. Had he flowed water a few seconds before I had the deluge gun completely off its base, the force of the water could have easily knocked it into my face.

Discussion Questions

Of the 18 contributing factor categories listed by the Firefighter Near-Miss Reporting System in Figure 1, how many do you feel fall into the human factors category? Did we include categories that you feel are not human factors? Why or why not?

鉴于上面的案例研究,categorie的因素s contributed to this near-miss incident?

References

1. Putnam, T. (n.d, n.d n.d). Dr. (T. Mason, Interviewer) Bureau of Land Management.

2. Retrieved January 25, 2011, from National Firefighter Near-Miss Reporting System:http://www.firefighternearmiss.com/Resources/Annual_Reports/Active_Resources/2008_Annual_Report.pdf.
3. LeSage, P., Dyar, J. T., & Evans, B. (2011).船员资源管理：原理和实践。Sudbury, MA: Jones and Bartlett Publishers, LLC.; Carley, D. A. (2010).Organizational and Group Influences on an Individual in a Fire Department Company.圣云州立大学。新罕布什尔州法戈：法戈消防局..

Craig Nelson(left)为Fargo（ND）消防部门工作，并在明尼苏达州立社区和技术学院兼职 - Moorhead担任消防教练。他还作为明尼苏达州西北部的野外消防员在明尼苏达州自然资源部季节性工作。188电竞足球比分以前，他是航空公司的飞行员。他拥有工商管理学士学位，并拥有执行消防领导层的硕士学位。

戴恩Carley(right)1989年在南加州进入消防局，目前是Fargo（ND）消防局的船长。从那时起，他一直在结构性，野生城市界面和野外消防，从消防探险家到职业队长的能力。188金博网网址多少他既拥有消防和安全工程技术学士学位，又拥有公共安全主管领导硕士学位。戴恩（Dane）还担任北达科他州III型事件管理援助团队的运营部门负责人，也是规划部门的负责人，该团队为当地司法管辖区提供了不知所措的支持。

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