the human factors analysis and classification system (hfacs) lcdr jeff alton human factors analyst...

The Human Factors Analysis and Classification The Human Factors Analysis and Classification System (HFACS)System (HFACS)

LCDR Jeff AltonHuman Factors Analyst

Naval Safety CenterAdapted from Shappell & Wiegmann, 2003

Direct Cost (FY 98 – 08) $5.14 Billion and 1113

Lives

Direct Cost (FY 98 – 08) $5.14 Billion and 1113

Lives

Indirect Cost Loss of Manpower

Delay in Doing Business

Corporate Reputation

Investigation Costs

Litigation

Indirect Cost Loss of Manpower

Delay in Doing Business

Corporate Reputation

Investigation Costs

Litigation

COSTS OF NAVAL ACCIDENTSCOSTS OF NAVAL ACCIDENTSCOSTS OF NAVAL ACCIDENTSCOSTS OF NAVAL ACCIDENTS

Source: U.S. Naval Safety CenterThru 15 Apr 08

Origins of (DOD) HFACS Starts with Reason’s “Swiss Cheese” model Based on Human Factors Analysis and Classification

System (HFACS) by Doug Weigmann & Scott Shappell Categorization of system failure in complex systems

– Latent Failures– Active Failures

Brings together human factors, Operations, Human systems, Systems safety and Engineering Issues– Man, Machine, Medium, Mission, Management

Philosophy of mishap analysis that focuses on the system instead of the individual– Original version used by USN as mishap analysis tool

DoD-HFACS is the follow-on product

Failed orAbsent Defenses

OrganizationalFactors

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Adapted from Reason (1990)

Accident & Injury

Reason’s “Swiss-cheese” Model of Human ErrorReason’s “Swiss-cheese” Model of Human Error

Errors

ACTS

Errors

PerceptionErrors

Skill-BasedErrors

Judgment andDecision-Making

Errors

Violations

InadequateSupervision

PlannedInappropriate

Operations

Failed to Correct Known Problem

SupervisoryViolations

SUPERVISION

Resource/AcquisitionManagement

OrganizationalClimate

OrganizationalProcess

ORGANIZATIONALINFLUENCES

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

Think decision tree Analysis starts with end result Traces back through the “decisions” and conditions Layers of Swiss Cheese are conditions at each level Some cheese has more holes than others…

– Poor command climate, no rules enforcement– Personnel fatigued, or poorly trained– Some environments more challenging

Goal – More solid cheese - or countermeasures to avoid the holes

Typical decision tree AKA “fish bones”

Why? Why?

0

5

10

15

20

25

30

35

40

45

50

Errors in Skill DecisionErrors

Perception PolicyViolations

Material Factor+ Human error

MaterialFailure

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of

Ep

iso

des

To reduce mishap rate, efforts must be focused on identifying the primary causes, which in most cases is the human.

Navy F/A-18 Class A Flight Mishaps

ACTSACTS

ViolationsErrorsErrors

MisperceptionErrors

Judgment and DecisionErrors

Skill-BasedErrors

UnsafeActs

UnsafeActs

DECISION ERRORSRisk Assessment – During OperationTask MisprioritizationNecessary Action – RushedNecessary Action – DelayedCaution/Warning – IgnoredWrong choice of action

ACTSACTS

ViolationsErrorsErrors

MisperceptionErrors

Judgment and DecisionErrors

Skill-BasedErrors

UnsafeActs

SKILL-BASED ERRORS

ACTSACTS

ViolationsErrorsErrors

MisperceptionErrors

Judgment and DecisionErrors

Skill-BasedErrors

Inadvertent OperationChecklist ErrorProcedural ErrorOvercontrol/UndercontrolBreakdown in Visual ScanInadequate Anti-G Straining Maneuver

UnsafeActs

MISPERCEPTION ERRORS(due to)

Misjudge Distance, Altitude, Airspeed Spatial Disorientation Visual Illusions

ACTSACTS

ViolationsErrorsErrors

MisperceptionErrors

Judgment and DecisionErrors

Skill-BasedErrors

UnsafeActs

ACTSACTS

ViolationsErrorsErrors

MisperceptionErrors

Judgment and DecisionErrors

Skill-BasedErrors VIOLATIONS

(Willful disregard for rules and instructions!)Violation – Work-aroundViolation – Routine/WidespreadViolation – Extreme

UnsafeActs

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

Preconditionsfor

Unsafe Acts

UnsafeActs

ActsThe act is the end result. It answers the question of, “what happened?”

Skill-based Errors: errors in regularly- performed tasks

Decision Errors: selection of an incorrect course of action for a particular situation

Perception Errors: perception of an illusion leads to an incorrect course of action

Violation: intentionally acting against written policy or procedures.

Preconditions

Physical environment: the working environment. Rain, darkness, cold, hot, etc.

Technological Environment: the tools used in the mission. Vehicle design and usability of associated systems

Self-imposed stress: things we do to ourselves – alcohol, lack of sleep, fitness level

Preconditions are the things that allow the unsafe acts to occur, and they answer the question of, “Why did it happen?” Broad categories are:

Preconditions (cont.)

Coordination, communication, planning: team interaction, mission planning (CRM)

Cognitive factors: situational awareness Physical/mental limitations: operator size

incompatible with workspace, trouble retaining information

Preconditions (cont.)

Perceptual factors: visual or proprioceptive illusions

Psycho-behavioral factors: personality problems, overconfidence, aggressiveness, etc.

Adverse Physiological States: fatigue, effects of medications, breathing difficulties

There may be more than one precondition for each act!

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 ENVIRONMENTIcing/Fog/Etc. on windowsMeteorological ConditionsDust/Smoke/Etc. in WorkspaceBrownout/WhiteoutThermal Stress: Cold/HotManeuvering Forces In-FlightNoise Interference

Preconditionsfor

Unsafe Acts

UnsafeActs

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

TECHNOLOGICALENVIRONMENT

Seating and RestraintsInstrument and Sensory Feedback Visibility RestrictionsControls and SwitchesAutomationPersonal Equipment InterferenceCommunications - Equipment

Physical Environment Condition of

Individuals

Preconditionsfor

Unsafe Acts

UnsafeActs

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/PLANCrew/Team LeadershipCross-Monitoring PerformanceTask DelegationRank/Position Authority GradientCommunicating Critical InfoStandard/Proper TerminologyMission Planning/BriefingMiscommunication

Condition of Individuals

Self-Imposed

Stress

Preconditionsfor

Unsafe Acts

UnsafeActs

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 STRESSAlcoholPhysical FitnessDrugs/Supplements/Self MedicationNutritionInadequate RestUnreported Disqualifying Medical Condition

Condition of Individuals

Preconditionsfor

Unsafe Acts

UnsafeActs

COGNITIVE FACTORSInattentionChannelized AttentionCognitive Task OversaturationConfusionNegative TransferDistractionGeographic 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

StatesPreconditionsfor

Unsafe Acts

UnsafeActs

PSYCHO-BEHAVIORAL Personality StylePre-Existing Personality DisorderPre-Existing Psychological DisorderEmotional StateOverconfidenceComplacencyGet-Home-Itis/Get-There-ItisOveraggressive

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

StatesPreconditionsfor

Unsafe Acts

UnsafeActs

ADVERSE PHYSIOLOGICAL Effects of G Forces (G-LOC, etc)Physical Fatigue (Overexertion)Fatigue – Physiological/MentalHypoxiaMotion SicknessCircadian Rhythm DesynchronyPre-Existing Physical Illness/InjuryPrescribed 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

FactorsPreconditionsfor

Unsafe Acts

UnsafeActs

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/RateMemory Ability/LapsesAnthropometric/Biomechanical LimitsMotor Skill/Coordination or Timing DeficiencyTechnical/Procedural Knowledge

Preconditionsfor

Unsafe Acts

UnsafeActs

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/VisualMisperception of Operational ConditionsMisinterpreted/Misread InstrumentExpectancyAuditory CuesSpatial Disorientation: 1, 2, & 3Temporal Distortion

Physical/Mental

LimitationsPreconditionsfor

Unsafe Acts

UnsafeActs

Supervision

Inadequate supervision: lack of guidance, written policy, or training opportunities

Failure to correct known problem: problems with personnel or operations

Inappropriate Operations: lack of proper risk assessment or assigned inappropriate personnel to task

Violations: unnecessarily allows operations outside of SOP

Supervisors are ultimately responsible for the conduct of their units.

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrect Known

Problem

SupervisoryViolations

SUPERVISIONSUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrect Known

Problem

SupervisoryViolations

SUPERVISIONSUPERVISION

INADEQUATE SUPERVISIONLeadership/Supervision/Oversight InadequateSupervision – ModelingLocal Training Issues/ProgramsSupervision – PolicySupervision – Personality ConflictSupervision – Lack of Feedback

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

PLANNED INAPPROPRIATEOPERATIONS

Ordered/Led Mission Beyond CapabilityCrew/Team/Flight Makeup/CompositionLimited Recent ExperienceLimited Total ExperienceProficiencyRisk Assessment – FormalAuthorized Unnecessary Hazard

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrect Known

Problem

SupervisoryViolations

SUPERVISIONSUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

FAILED TO CORRECT AKNOWN PROBLEM

Personnel ManagementOperations Management

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrect Known

Problem

SupervisoryViolations

SUPERVISIONSUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

SUPERVISORY VIOLATIONSSupervision – Discipline EnforcementSupervision – Unwritten PolicyDirected ViolationAssigned Unqualified Individuals

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrect Known

Problem

SupervisoryViolations

SUPERVISIONSUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Organizational Factors

Resource/Acquisition Management: the ways in which equipment is allocated

Organizational Climate: affects morale in a unit

Process: policies and procedures that drive the concept of operations

The Organization is responsible for overall policy, doctrine, and allocation of resources to the subordinate units

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

Resource/AcquisitionManagement

Resource/AcquisitionManagement

OrganizationalProcess

ORGANIZATIONALINFLUENCES

RESOURCE/ACQUISITIONMANAGEMENT

Air Traffic Control ResourcesAirfield ResourcesOperator SupportAcquisition Policies/Design ProcessesAttrition PoliciesAccession/Selection PoliciesPersonnel ResourcesInformation Resources/SupportFinancial Resources/Support

OrganizationalClimate

ORGANIZATIONALINFLUENCES

ORGANIZATIONALINFLUENCES

OrganizationalClimate

ORGANIZATIONALCLIMATE

Unit/Organizational Values/Culture Evaluation/Promotion/UpgradePerceptions of EquipmentUnit Mission/Aircraft ChangeUnit DeactivationOrganizational Structure

Resource/AcquisitionManagement

Resource/AcquisitionManagement

OrganizationalProcess

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

OperationalProcess

ORGANIZATIONALINFLUENCES

ORGANIZATIONALINFLUENCES

OrganizationalProcess

ORGANIZATIONALPROCESS

Ops Tempo/WorkloadProgram and Policy Risk AssessmentProcedural Guidance/PublicationsOrganizational Training Issues/ProgramsDoctrineProgram Oversight/Program Management

Resource/AcquisitionManagement

Resource/AcquisitionManagement

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

HFACS Example

H-60 enters out of control flight after loss of tail rotor authority. Aircraft becomes uncontrollable resulting in a hard landing and rollover. Engineering investigation reveals improperly installed tail-rotor mechanism pin.

DoD HFACS Coding

Act: Procedure performed incorrectly (AE103). Tail rotor cotter pin not correctly installed

Preconditions: warning systems (PE202). Lack of written warning for improperly installed pin

Supervisory: inadequate oversight (SI001). QA missed improper pin placement

Organizational: Informational resources (OR008). Lack of O-level diagram showing pin placement in relation to all other holes.

Flawed Doctrine (OP005). Army had solved the problem several years before. Info not made part of Navy maintenance

QuestionsQuestions??