human factors analysis and classification system hfacs

30. What my guys at the Safety Center did was define the holes in the cheese using a classification system they call the Human Factors Analysis and Classification System (HFACS). Now before you get all excited, we don�t expect you to know all the inner workings of HFACS -- just be familiar with the concept. Your Flight Surgeon has had extensive training on this investigative tool while training at NOMI (some of you may remember it as NAMI). He/she will be your subject matter experts in the field, during briefs and God forbid, during mishap investigations. What I want you to understand now is that we view HFACS as the first step in the risk management process -- The identification of hazards. We have had tremendous success using this tool already. Notice that my folks have defined the holes at each level. Peeling the human factors onion back until we can get at the root of the problem. Take the Unsafe Acts of Aircrew level for instance. Unsafe Acts can be broken down into to two general categories: Errors and Violations. Now we all know what violations are and we would like to believe that they don�t occur often. But let me tell you, 40% of all Naval aviation mishaps associated with Human Factors have violations associated with them. Not surprisingly, aircrew error is identified in nearly all Naval aviation mishaps as well (often as the last fatal flaw in the chain of events). But that�s NOT where the fix is (or to use risk management terms) where the controls should be placed. The fix is higher in the system at the precondition, supervisory and organizational level. For instance, it�s not surprising that with current fiscal constraints and down-sizing the human, material and monetary assets are lacking to maintain proficiency. Consequently, supervisors are being forced to �do more with less� leading to poor crew pairing and overworked crews and maintainers. This leads to mental fatigue which will ultimately lead to errors in the cockpit! Where�s the fix? Certainly not at the flight crew level. We�ve been aiming at the aircrew for years and haven�t made a dent. We will have to focus higher in the system if we want to effect change. This is what HFACS brings to the table. It�s not another program or requirement to be shouldered by the Line. It�s a tool to assist you in identifying and controlling hazards. Be familiar with it! What my guys at the Safety Center did was define the holes in the cheese using a classification system they call the Human Factors Analysis and Classification System (HFACS). Now before you get all excited, we don�t expect you to know all the inner workings of HFACS -- just be familiar with the concept. Your Flight Surgeon has had extensive training on this investigative tool while training at NOMI (some of you may remember it as NAMI). He/she will be your subject matter experts in the field, during briefs and God forbid, during mishap investigations. What I want you to understand now is that we view HFACS as the first step in the risk management process -- The identification of hazards. We have had tremendous success using this tool already. Notice that my folks have defined the holes at each level. Peeling the human factors onion back until we can get at the root of the problem. Take the Unsafe Acts of Aircrew level for instance. Unsafe Acts can be broken down into to two general categories: Errors and Violations. Now we all know what violations are and we would like to believe that they don�t occur often. But let me tell you, 40% of all Naval aviation mishaps associated with Human Factors have violations associated with them. Not surprisingly, aircrew error is identified in nearly all Naval aviation mishaps as well (often as the last fatal flaw in the chain of events). But that�s NOT where the fix is (or to use risk management terms) where the controls should be placed. The fix is higher in the system at the precondition, supervisory and organizational level. For instance, it�s not surprising that with current fiscal constraints and down-sizing the human, material and monetary assets are lacking to maintain proficiency. Consequently, supervisors are being forced to �do more with less� leading to poor crew pairing and overworked crews and maintainers. This leads to mental fatigue which will ultimately lead to errors in the cockpit! Where�s the fix? Certainly not at the flight crew level. We�ve been aiming at the aircrew for years and haven�t made a dent. We will have to focus higher in the system if we want to effect change. This is what HFACS brings to the table. It�s not another program or requirement to be shouldered by the Line. It�s a tool to assist you in identifying and controlling hazards. Be familiar with it!