the human factors analysis and classification system (hfacs) lcdr jeff alton human factors analyst...
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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
Nu
mb
er
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??