The DoD Human Factors Analysis and Classification System (HFACS)

1. The DoD Human Factors Analysis and Classification System (HFACS) May 2006

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

3. 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

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

5. 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 • Decision-Making During Operation

6. 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

7. 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

8. Unsafe Acts ACTS Errors Violations Misperception Errors Judgment and Decision Errors Skill-Based Errors VIOLATIONS (Willful disregard for rules and instructions!) • Violation – Based on Risk Assessment • Violation – Routine/Widespread • Violation – Lack of Discipline

9. 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 Preconditions for Unsafe Acts Unsafe Acts

10. PRECONDITIONS Preconditions for Unsafe Acts PHYSICAL 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 • Icing/Fog/Etc. on windows • Meteorological Conditions • Dust/Smoke/Etc. in Workspace • Brownout/Whiteout • Thermal Stress: Cold/Hot • Maneuvering Forces In-Flight • Noise Interference

11. 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

12. 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 Briefing • Miscommunication

13. 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 • Physical Fitness • Alcohol • Drugs/Supplements/Self Medication • Nutrition • Inadequate Rest • Unreported Disqualifying Medical Condition

14. 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

15. 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 • Pre-Existing Personality Disorder • Pre-Existing Psychological Disorder • Emotional State • Personality Style • Overconfidence • Complacency • Get-Home-Itis/Get-There-Itis • Overaggressive

16. 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 Drugs

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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 – De Facto Policy • Directed Violation • Currency

24. ORGANIZATIONAL INFLUENCES Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Resource/Acquisition Management Organizational Climate Organizational Process

25. ORGANIZATIONAL INFLUENCES Resource/Acquisition Management Organizational Climate Organizational Process Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts RESOURCE/ACQUISITION MANAGEMENT • 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

26. 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 • Organizational Structure

27. 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

28. 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