The DoD Human Factors Analysis and Classification System (HFACS)

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

2. “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997 It is not surprising then, that human error has been implicated in 60-90% of all accidents. However, the rate of human error accidents has remained relatively stable over the past 20 years, whereas accidents associated with mechanical failures have been virtually eliminated.

3. Mishaps The cost of doing business? • Purpose of Mishap Analysis? (Remember the 3 W’s) • What Happen ? • Why it Happened ? • What to do to prevent it ?

4. Developed at the Navy Safety Center in the late 1980’s Based on various theories of human error Originally intended for aviation operations 2006 version refined for use in any operational and off-duty event Used as a retrospective analysis tool – a reanalysis of MAB facts/findings with this tool Did not go into the MAR HFACS: Background

5. Structured analysis of human error Sophisticated, complete…yet operational Detects error patterns current methods miss Get to the “why”… not just the “what” More insightful root cause determination Better CO decisions… more effective ORM A new, data-driven approach Supports research across the Force Easily applied to large body of existing data Easily applied to new incidents and mishaps Can be used for more than Operational purposes Can be a tool for Risk Management Applies to both on-duty and off-duty evolutions HFACS: Benefits

6. HFACS: Tiers Organizational Latent Failures/Conditions Supervision Preconditions Acts Active Failures Deficient or Immature Conditions Accident & Injury Adapted from Reason (1990)

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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 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

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 SELF-IMPOSED STRESS • Physical Fitness • Alcohol • Drugs/Supplements/Self Medication • Nutrition • Inadequate Rest • Unreported Disqualifying Medical Condition

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 COGNITIVE FACTORS • Inattention • Channelized Attention • Cognitive Task Oversaturation • Confusion • Negative Transfer • Distraction • Geographic Misorientation (Lost) • Checklist Interference

19. 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

20. 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 Injury/Illness

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 PHYSICAL/MENTAL LIMITS • Learning Ability/Rate • Memory Ability/Lapses • Anthropometric/Biomechanical Limits • Motor Skill/Coordination or Timing Deficiency • Technical/Procedural Knowledge

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 PERCEPTUAL FACTORS • Illusions: Kinesthetic/Vestibular/Visual • Misperception of Operational Conditions • Misinterpreted/Misread Instrument • Expectancy • Auditory Cues • Spatial Disorientation: 1, 2, & 3 • Temporal Distortion

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

24. 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

25. 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

26. 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

27. 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

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

29. 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

30. 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

31. 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

32. 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

36. Night Watch - 150

37. Night Watch - 150

38. Integrate HFACS into the mishap investigation process All MAB members participate in the HFACS analysis (NOT JUST SAFETY and MEDICAL OFFICER) read DoD HFACS Guide to know the process and factors (nanacodes) conduct preliminary HFACS analysis on mishap message info Use HFACS to plan and conduct the ‘fact finding’ and interview process Seek evidence to accept or reject ‘nanacodes’ Document facts/evidence that justifies selecting the ‘nanocode’ Identify which nanocodes are “causal” and which are “contributing” Causal – direct link to the mishap or respond “NO” to the question, would the mishap have occurred if the nanocode was removed? Contributory – no direct link to the mishap and respond “YES” to the question, would the mishap have occurred if the nanocode was removed? Conduct a flow analysis to identify the interaction and influence of all the nanacodes to the mishap HFACS: Approach

39. PC307 Fatigue (Physiological/Mental): Both the qualified coxswain and the break-in coxswain stated they were well rested and alert. However, numerous boat crew members expressed being tired and getting little sleep (3-4 hours) during the previous days. Watch logs confirmed that some of the boat crew stood watch that night or morning. Unfortunately, 72-hour histories were not provided to conduct endurance assessments, but the vast majority of crew interviewed claimed to have 3-5 hours of sleep the night prior. The CO gave order “slow and steady”, a typical behavioral countermeasure for when an individual is compromised due to fatigue. Individuals realize their physical and cognitive states may be “dulled” due to fatigue, and thus slow down and verify everything they do. HFACS: Documentation

40. HFACS: Analysis Limited Recent Experience (SP003) Workspace Incompatible with Human (PE206) Get There It Is (PC213) Negative Transfer (PC105) Local Training Issue (SI003) Complacency (PC208) Overcontrol/ Undercontrol (AE104) Distraction (PC106) Risk Assessment – During Ops (AE204) Breakdown of visual scan (AE105) Inattention (PC101) Capsize Necessary Action Delayed (AE204) Fatigue (PC307) Ops Tempo/Workload (OP001) Cross-Monitoring Performance(PP102) Unit/Org Values/ Culture (OC001) Risk Assessment – Formal (SP006) Red HFACS = Causal Black HFACS = Contributory 40

41. Training - flight surgeons and safety personnel Update HFACS User Guide E-Mishap system updated Expand use of HFACS beyond Class A/B mishaps Risk management tool HFACS: Status

42. Case Scenario I

43. 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

44. HFACS • Acts • Breakdown visual scan • Risk Assessment • Preconditions • Distraction • Communicating Critical Information* • Mission Planning

45. HFACS • Supervision • Failure to correct known problem • Operations mgmt • Organization • Airfield Resources (Unsafe Track Condition)

46. Poor Risk Assessment Poor Mission Planning Failure to Correct Known Problem Distraction Unsafe Track Condition Pole Strike Brkdwnvis scan Commm Critical Information

47. Antonio “Tony” Carvalhais, Ph.D. CG Headquarters Office of Safety and Environmental Health (CG-113) 2100 2nd Street SW Washington, DC 20593 202-475-5213 (phone) 202-475-5910 (fax) antonio.b.carvalhais@uscg.mil http://www.uscg.mil/safety POINT OF CONTACT