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    Mishap-Level Person-Level Factors Diagram

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    Wilson Benincore
    The document outlines various organizational and individual factors that can influence mishaps across multiple levels. At the organizational level, it lists resource problems, personnel issues, policy/process problems, and cultural influences within an organization. It then discusses supervision factors like violations, inappropriate operations, and inadequate supervision. Finally, it outlines preconditions at the individual level relating to the physical and technological environment, physical/mental state, sensory misperceptions, and mental awareness.

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    Mishap-Level Person-Level Factors Diagram

    Uploaded by

    Wilson Benincore
    6 views1 page
    The document outlines various organizational and individual factors that can influence mishaps across multiple levels. At the organizational level, it lists resource problems, personnel issues, policy/process problems, and cultural influences within an organization. It then discusses supervision factors like violations, inappropriate operations, and inadequate supervision. Finally, it outlines preconditions at the individual level relating to the physical and technological environment, physical/mental state, sensory misperceptions, and mental awareness.

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    Mishap-Level_Person-Level_Factors_Diagram

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    The document outlines various organizational and individual factors that can influence mishaps across multiple levels. At the organizational level, it lists resource problems, personnel issues, policy/process problems, and cultural influences within an organization. It then discusses supervision factors like violations, inappropriate operations, and inadequate supervision. Finally, it outlines preconditions at the individual level relating to the physical and technological environment, physical/mental state, sensory misperceptions, and mental awareness.

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    6 views1 page

    Mishap-Level Person-Level Factors Diagram

    Uploaded by

    Wilson Benincore
    The document outlines various organizational and individual factors that can influence mishaps across multiple levels. At the organizational level, it lists resource problems, personnel issues, policy/process problems, and cultural influences within an organization. It then discusses supervision factors like violations, inappropriate operations, and inadequate supervision. Finally, it outlines preconditions at the individual level relating to the physical and technological environment, physical/mental state, sensory misperceptions, and mental awareness.

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    of 1

    Mishap‐Level Factors

    ORGANIZATIONAL INFLUENCES

    Resource Problems Personnel Selection & Staffing Policy & Process Issues Climate/Culture Influences

    OR001 Command & Control Resources are OS001Personnel Recruiting & OC001 Organizational Culture (attitude/ actions) Allows
    Deficient Selection Policies are Inadequate OP001 Pace of Ops‐tempo/Workload for Unsafe Task/Mission
    OR003 Inadequate Infrastructure OS002Failure to Provide Adequate OP002 Organizational Program/Policy Risks not Adequately OC003 Organizational Over‐confidence or Under‐
    OR005 Failure to Remove Inadequate/ Manning/ Staffing Resources Assessed confidence in Equipment
    Worn‐out Equipment in Timely Manner OP003 Provided Inadequate Procedural Guidance or OC004 Unit Mission/Aircraft/Vehicle/Equipment
    OR008 Failure to Provide Adequate Operational Publications Change or Unit Deactivation
    Information Resources OP004 Organizational (formal) Training is Inadequate or OC005 Organizational Structure is Unclear or Inadequate
    OR009 Failure to Provide Adequate Funding Unavailable
    OP005 Flawed Doctrine/Philosophy
    OP006 Inadequate Program Management
    OP007Purchasing or Providing Poorly Designed or Unsuitable
    Equipment

    SUPERVISION

    Supervisory Violations Planned Inappropriate Operations Inadequate Supervision

    SV001 Failure to Enforce Existing Rules SP001 Directed Task Beyond Personnel Capabilities SI001 Supervisory/Command Oversight Inadequate
    SV002 Allowing Unwritten Policies to Become SP002 Inappropriate Team Composition SI002 Improper Role‐modeling
    Standard SP003 Selected Individual with Lack of Current or Limited Experience SI003 Failed to Provide Proper Training
    SV003 Directed Individual to Violate Existing SP006 Performed Inadequate Risk Assessment ‐Formal SI004 Failed to Provide Appropriate Policy/Guidance
    Regulations SP007 Authorized Unnecessary Hazard SI005 Personality Conflict with Supervisor
    SV004 Authorized Unqualified Individuals for Task SI006 Lack of Supervisory Responses to Critical Information
    SI007 Failed to Identify/Correct Risky or Unsafe Practices
    SI008 Selected Individual with Lack of Proficiency

    Person‐Level Factors
    PRECONDITIONS

    Environment Physical and Mental State

    Physical Environment Technological Environment Teamwork

    PE101 Environmental Conditions Affecting Vision PE201 Seat and Restraint System Problems PP101 Failure of Crew/Team Leadership
    PE103 Vibration Effects Vision or Balance PE202 Instrumentation & Warning System Issues PP103 Inadequate Task Delegation
    PE106 Heat/Cold Stress Impairs Performance PE203 Visibility Restrictions (Not Weather Related) PP104 Rank/Position Intimidation
    PE108 External Force or Object Impeded an PE204 Controls and Switches are Inadequate PP105 Lack of Assertiveness
    Individual’s Movement PE205 Automated System Creates Unsafe PP106 Critical Information Not Communicated
    PE109 Lights of Other Vehicle/Vessel/Aircraft Situation PP107 Standard/Proper Terminology Not Used
    Affected Vision PE206 Workspace Incompatible with Operation PP108 Failed to Effectively Communicate
    PE110 Noise Interference PE207 Personal Equipment Interference PP109 Task/Mission Planning/Briefing Inadequate
    PE208 Communication Equipment Inadequate

    Physical Problem State of Mind Sensory Misperception Mental Awareness

    PC302 Substance Effects (Alcohol, Supplements, PC202 Psychological Problem PC501 Motion Illusion ‐ Kinesthetic PC101 Not Paying Attention
    Medications, Drugs) PC203 Life Stressors PC502 Turning Illusion/Balance ‐ Vestibular PC102 Fixation
    PC304 Loss of consciousness (Sudden or Prolonged PC204 Emotional State PC503 Visual Illusion PC103 Task Over/Under Saturation
    Onset) PC205 Personality Style PC504 Misperception of Changing PC104 Confusion
    PC305 Physical Illness/Injury PC206 Overconfidence Environment PC105 Negative Habit Transfer
    PC307 Fatigue PC207 Pressing PC505 Misinterpreted/ Misread Instrument PC106 Distraction
    PC310 Trapped Gas Disorders PC208 Complacency PC507 Misinterpretation of Auditory/Sound PC107 Geographically Lost
    PC311 Evolved Gas Disorders PC209 Motivation Cues PC108 Interference/Interruption
    PC312 Hypoxia/Hyperventilation PC215 Motivational Exhaustion (Burnout) PC508 Spatial Disorientation PC109Technical or Procedural Knowledge Not
    PC314 Inadequate Adaptation to Darkness PC511 Temporal/Time Distortion Retained After Training
    PC315 Dehydration PC110 Inaccurate Expectation
    PC317 Body Size/Movement Limitations
    PC318 Physical Strength & Coordination (Inappropriate
    for Task Demands)
    PC319 Nutrition/Diet

    ACTS

    Performance‐Based Errors Judgment & Decision‐Making Errors Violations

    AE101 Unintended Operation of Equipment AE201 Inadequate Real‐Time Risk Assessment AV001 Performs Work‐Around Violation
    AE102 Checklist Not Followed Correctly AE202 Failure to Prioritize Tasks Adequately AV002 Commits Widespread/Routine Violation
    AE103 Procedure Not Followed Correctly AE205 Ignored a Caution/Warning AV003 Extreme Violation ‐ Lack of Discipline
    AE104 Over‐Controlled/Under‐Controlled AE206 Wrong Choice of Action During an Operation
    Aircraft/Vehicle/System
    AE105 Breakdown in Visual Scan
    AE107 Rushed or Delayed a Necessary Action

    22

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