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The DoD Human Factors Analysis and Classification System (HFACS). “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997.

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slide2

“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.

slide3

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 ?
hfacs background
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
hfacs benefits
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
slide6

HFACS: Tiers

Organizational

Latent Failures/Conditions

Supervision

Preconditions

Acts

Active Failures

Deficient or Immature

Conditions

Accident & Injury

Adapted from Reason (1990)

slide7

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

slide8

Unsafe

Acts

ACTS

Errors

Violations

Misperception

Errors

Judgment and Decision

Errors

Skill-Based

Errors

slide9

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
slide10

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
slide11

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
slide12

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
slide13

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

slide14

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
slide15

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
slide16

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
slide17

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
slide18

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
slide19

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
slide20

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
slide21

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
slide22

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
slide23

SUPERVISION

Planned

Inappropriate

Operations

Failed to

Correct Known

Problem

Supervisory

Violations

Inadequate

Supervision

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

slide24

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
slide25

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
slide26

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
slide27

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
slide28

ORGANIZATIONAL

INFLUENCES

Organizational

Influences

Unsafe

Supervision

Preconditions

for

Unsafe Acts

Unsafe

Acts

Resource/Acquisition

Management

Organizational

Climate

Organizational

Process

slide29

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
slide30

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
slide31

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
slide32

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

hfacs approach
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
hfacs documentation
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
hfacs analysis
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

hfacs status
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
slide43

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

hfacs
HFACS
  • Acts
    • Breakdown visual scan
    • Risk Assessment
  • Preconditions
    • Distraction
    • Communicating Critical Information*
    • Mission Planning
hfacs45
HFACS
  • Supervision
    • Failure to correct known problem
      • Operations mgmt
  • Organization
    • Airfield Resources (Unsafe Track Condition)
slide46

Poor

Risk Assessment

Poor

Mission Planning

Failure to Correct

Known Problem

Distraction

Unsafe Track

Condition

Pole Strike

Brkdwnvis scan

Commm Critical

Information

point of contact
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