Human Factors Analysis and Classification System (HFACS)

1. Organizational Factors Unsafe Acts Pre-Conditions for Unsafe Acts Unsafe Supervision Human Factors Analysis and Classification System (HFACS)

2. Swiss Cheese Model

3. Errors Violations Perceptual Errors Skill-based Errors Decision Errors Routine Exceptional Unsafe Acts UNSAFE ACTS

4. PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Management Non-Supervisory Tolerance of Unsafe Acts Personal Readiness Preconditions for Unsafe Acts Unsafe Acts

5. Unforeseen Known Inadequate Documentation/ Procedures Failure to Correct Problem Supervisory Violations Unrecognized Hazardous Operations Inadequate Supervision Planned Inappropriate Operations Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts UNSAFE SUPERVISION

6. ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Operational Process Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

7. Organizational Factors Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Failures in your System’s Defenses Human Factors Analysis Provides More than just an Accident Investigation Tool Opportunity for Pro-active Action by Management