Page 19 - HFACS Flipbook Holcim v 1.2

PRECONDITIONS FOR UNSAFE ACTS

SITUATIONAL FACTORS

Physical Environment
● How would you describe the situation in the room/
location at the time of the event? (Was it chaotic? Were
there a lot of distractions/interruptions? Was it difficult to
concentrate on what you were doing?)
● How would you describe the physical environment you
were working in? (Was it adequately illuminated? Was
there a lot of noise in the room? Was there anything
that interfered with your ability to see or hear important
information?)
● How would you describe the layout of the workspace you
were in? (Was it small, crowded, cluttered and/or
disorganized? Was the work area designed to support the
function it was being used for?)

Tools/Technology
● Did existing documentation provide adequate
information? (Did orders, progress notes, records, etc.,
provide a clear picture of the plan?)
● Was there anything wrong with the equipment being used
at the time of the event? (Were the displays, controls
and/or alarms working properly? Was any of the
equipment outdated, poorly maintained or
malfunctioning?)
● Was the use of the equipment effectively integrated
into the workflow? (Was it conveniently located, or did it
create extra work? Was its use smoothly integrated with
the clinical activities or procedures related to the event?

2022 Holcim Group HSE