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The Human Factors Analysis and Classification System (HFACS)

The Human Factors Analysis and Classification System (HFACS). LCDR Jeff Alton Human Factors Analyst Naval Safety Center. Adapted from Shappell & Wiegmann, 2003. COSTS OF NAVAL ACCIDENTS. Direct Cost (FY 98 – 08) $5.14 Billion and 1113 Lives. Indirect Cost Loss of Manpower

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The Human Factors Analysis and Classification System (HFACS)

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  1. The Human Factors Analysis and Classification System (HFACS) LCDR Jeff Alton Human Factors Analyst Naval Safety Center Adapted from Shappell & Wiegmann, 2003

  2. COSTS OF NAVAL ACCIDENTS • 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 Source: U.S. Naval Safety Center Thru 15 Apr 08

  3. 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 Origins of (DOD) HFACS

  4. Organizational Factors Reason’s “Swiss-cheese” Model of Human Error Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Failed or Absent Defenses Accident & Injury Adapted from Reason (1990)

  5. ORGANIZATIONAL INFLUENCES Resource/Acquisition Management Organizational Climate Organizational Process SUPERVISION Planned Inappropriate Operations Failed to Correct Known Problem Inadequate Supervision Supervisory Violations PRECONDITIONS Environmental Factors Personnel Factors Coordination/ Communication/ Planning Factors Self-Imposed Stress Physical Environment Technological Environment Condition of Individuals Psycho-Behavioral Factors Adverse Physiological States Physical/ Mental Limitations Perceptual Factors Cognitive Factors ACTS Errors Errors Violations Judgment and Decision-Making Errors Skill-Based Errors Perception Errors

  6. 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 Think decision tree

  7. Typical decision tree AKA “fish bones”

  8. Why? 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

  9. ACTS Errors Violations Misperception Errors Judgment and Decision Errors Skill-Based Errors Unsafe Acts Unsafe Acts

  10. Judgment and Decision Errors Unsafe Acts ACTS Errors Violations Misperception Errors Skill-Based Errors DECISION ERRORS • Risk Assessment – During Operation • Task Misprioritization • Necessary Action – Rushed • Necessary Action – Delayed • Caution/Warning – Ignored • Wrong choice of action

  11. ACTS Errors Violations Misperception Errors Judgment and Decision Errors Skill-Based Errors Unsafe Acts SKILL-BASED ERRORS • Inadvertent Operation • Checklist Error • Procedural Error • Overcontrol/Undercontrol • Breakdown in Visual Scan • Inadequate Anti-G Straining Maneuver

  12. Unsafe Acts ACTS Errors Violations Misperception Errors Judgment and Decision Errors Skill-Based Errors MISPERCEPTION ERRORS (due to) • Misjudge Distance, Altitude, Airspeed • Spatial Disorientation • Visual Illusions

  13. Unsafe Acts ACTS Errors Violations Misperception Errors Judgment and Decision Errors Skill-Based Errors VIOLATIONS (Willful disregard for rules and instructions!) • Violation – Work-around • Violation – Routine/Widespread • Violation – Extreme

  14. PRECONDITIONS Preconditions for Unsafe Acts Unsafe Acts Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Cognitive Factors Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors

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

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

  17. 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.)

  18. 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! Preconditions (cont.)

  19. PRECONDITIONS PHYSICAL ENVIRONMENT Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors Preconditions for Unsafe Acts • Icing/Fog/Etc. on windows • Meteorological Conditions • Dust/Smoke/Etc. in Workspace • Brownout/Whiteout • Thermal Stress: Cold/Hot • Maneuvering Forces In-Flight • Noise Interference Unsafe Acts

  20. PRECONDITIONS Preconditions for Unsafe Acts TECHNOLOGICAL ENVIRONMENT Unsafe Acts Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors • Seating and Restraints • Instrument and Sensory Feedback • Visibility Restrictions • Controls and Switches • Automation • Personal Equipment Interference • Communications - Equipment

  21. Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors COORD/COMM/PLAN • Crew/Team Leadership • Cross-Monitoring Performance • Task Delegation • Rank/Position Authority Gradient • Communicating Critical Info • Standard/Proper Terminology • Mission Planning/Briefing • Miscommunication

  22. Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors SELF-IMPOSED STRESS • Alcohol • Physical Fitness • Drugs/Supplements/Self Medication • Nutrition • Inadequate Rest • Unreported Disqualifying Medical Condition

  23. Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors COGNITIVE FACTORS • Inattention • Channelized Attention • Cognitive Task Oversaturation • Confusion • Negative Transfer • Distraction • Geographic Misorientation (Lost) • Checklist Interference

  24. Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors PSYCHO-BEHAVIORAL • Personality Style • Pre-Existing Personality Disorder • Pre-Existing Psychological Disorder • Emotional State • Overconfidence • Complacency • Get-Home-Itis/Get-There-Itis • Overaggressive

  25. Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Physical/ Mental Limitations Perceptual Factors Psycho-Behavioral Factors ADVERSE PHYSIOLOGICAL • Effects of G Forces (G-LOC, etc) • Physical Fatigue (Overexertion) • Fatigue – Physiological/Mental • Hypoxia • Motion Sickness • Circadian Rhythm Desynchrony • Pre-Existing Physical Illness/Injury • Prescribed Meds for Injury/Illness

  26. Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors PHYSICAL/MENTAL LIMITS • Learning Ability/Rate • Memory Ability/Lapses • Anthropometric/Biomechanical Limits • Motor Skill/Coordination or Timing Deficiency • Technical/Procedural Knowledge

  27. Preconditions for Unsafe Acts Unsafe Acts PRECONDITIONS Environmental Factors Personnel Factors Physical Environment Technological Environment Coordination/ Communication/ Planning Factors Self-Imposed Stress Condition of Individuals Adverse Physiological States Cognitive Factors Psycho-Behavioral Factors Physical/ Mental Limitations Perceptual Factors PERCEPTUAL FACTORS • Illusions: Kinesthetic/Vestibular/Visual • Misperception of Operational Conditions • Misinterpreted/Misread Instrument • Expectancy • Auditory Cues • Spatial Disorientation: 1, 2, & 3 • Temporal Distortion

  28. 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 Supervision Supervisors are ultimately responsible for the conduct of their units.

  29. SUPERVISION Planned Inappropriate Operations Failed to Correct Known Problem Supervisory Violations Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

  30. Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts SUPERVISION Planned Inappropriate Operations Failed to Correct Known Problem Supervisory Violations Inadequate Supervision INADEQUATE SUPERVISION • Leadership/Supervision/Oversight Inadequate • Supervision – Modeling • Local Training Issues/Programs • Supervision – Policy • Supervision – Personality Conflict • Supervision – Lack of Feedback

  31. SUPERVISION Planned Inappropriate Operations Failed to Correct Known Problem Supervisory Violations Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts PLANNED INAPPROPRIATE OPERATIONS • Ordered/Led Mission Beyond Capability • Crew/Team/Flight Makeup/Composition • Limited Recent Experience • Limited Total Experience • Proficiency • Risk Assessment – Formal • Authorized Unnecessary Hazard

  32. SUPERVISION Planned Inappropriate Operations Failed to Correct Known Problem Supervisory Violations Inadequate Supervision Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts FAILED TO CORRECT A KNOWN PROBLEM • Personnel Management • Operations Management

  33. SUPERVISION Planned Inappropriate Operations Failed to Correct Known Problem Supervisory Violations Inadequate Supervision Unsafe Supervision SUPERVISORY VIOLATIONS Preconditions for Unsafe Acts Unsafe Acts • Supervision – Discipline Enforcement • Supervision – Unwritten Policy • Directed Violation • Assigned Unqualified Individuals

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

  35. ORGANIZATIONAL INFLUENCES Resource/Acquisition Management Organizational Climate Organizational Process Organizational Influences RESOURCE/ACQUISITION MANAGEMENT Unsafe Supervision • Air Traffic Control Resources • Airfield Resources • Operator Support • Acquisition Policies/Design Processes • Attrition Policies • Accession/Selection Policies • Personnel Resources • Information Resources/Support • Financial Resources/Support Preconditions for Unsafe Acts Unsafe Acts

  36. ORGANIZATIONAL INFLUENCES Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts ORGANIZATIONAL INFLUENCES Resource/Acquisition Management Organizational Climate Organizational Climate Organizational Process ORGANIZATIONAL CLIMATE • Unit/Organizational Values/Culture • Evaluation/Promotion/Upgrade • Perceptions of Equipment • Unit Mission/Aircraft Change • Unit Deactivation • Organizational Structure

  37. ORGANIZATIONAL INFLUENCES Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts ORGANIZATIONAL INFLUENCES Resource/Acquisition Management Organizational Climate Operational Process Organizational Process ORGANIZATIONAL PROCESS • Ops Tempo/Workload • Program and Policy Risk Assessment • Procedural Guidance/Publications • Organizational Training Issues/Programs • Doctrine • Program Oversight/Program Management

  38. 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. HFACS Example

  39. 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 DoD HFACS Coding

  40. Questions?

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