The Dirty Dozen highlights the most frequently observed human-related issues discovered during Fiscal Year 2022 agency mishaps and close-call investigations. Throughout the year, these issues contributed to $3,310,298.74 in damage costs and 630 workdays of lost time.
1) DECISION-MAKING ERRORS
We make conscious decisions all the time, and when those decisions don’t go as taught or intended, they can result in an unsafe situation (e.g., ignored caution or warning, inadequate
risk assessment).
2) COMMUNICATION
Information transfer breakdowns are involved in most all mishaps (e.g., inadequate briefing, risk assessment, miscommunication, failure to communicate critical information).
3) ORGANIZATIONAL OPERATIONS
Policies, processes and procedures are critical and need to be available, accurate, and consistent for successful operations (e.g., design reviews, flight readiness reviews, NPRs, audits).
4) TECHNOLOGICAL ENVIRONMENT
Technology is an essential element of our mission. When technological tools fail to perform or underperform, it creates risks (e.g., communication equipment, warning system, switches and controls).
5) INADEQUATE SUPERVISION
Supervisors who don’t provide enough guidance and mentoring put their subordinates at greater risk (e.g., modeling, lack of feedback, training).
6) SKILL-BASED ERRORS
We perform routine patterns of behavior easily and unconsciously over time. These patterns are learned, and when they break down, it creates unsafe situations (e.g., procedural error, improper technique, checklist discipline)
7) PLANNED INAPPROPRIATE OPERATIONS
Supervisors who plan inappropriate work (but not a violation) put their colleagues and mission at greater risk (e.g., team or crew composition, pushing operational tempo).
8) ORGANIZATIONAL RESOURCES
Our organization provides tools to conduct business successfully (e.g., staffing, budget, equipment, facilities, technology, data systems).
9) ADVERSE PSYCHOLOGICAL
Mental states affect our interactions in ways that impact successful work operations (e.g., emotional state, personality, peer pressure, mental fatigue, motivation).
10) VIOLATIONS
Routine and workaround violations are tolerated by the organization when coworkers, supervisors, managers or leaders “look away” (e.g., driving over speed limit). Extreme violations are when
one deliberately engages in behavior and knowingly violates rules (e.g., flying inverted)
11) ORGANIZATIONAL CULTURE / CLIMATE
When the attitudes, values, beliefs, or morale of the people within an organization impact operations or operational risk.
12) COGNITIVE FACTORS
Attention management conditions affect an individual’s performance and can create an unsafe environment (e.g., channelized attention, negative habit transfer, distraction, inattention)