HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS)

1. HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) THE FIRST STEP IN THE RISK MANAGEMENT PROCESS

2. “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

3. 776 aircraft destroyed in 1954 39 aircraft destroyed in 1996 NAVAL AVIATION MISHAP RATE FY 50-96 Angled Carrier Decks Naval Aviation Safety Center NAMP est. 1959 RAG concept initiated NATOPS initiated 1961 Squadron Safety program System Safety Designated Aircraft ACT HFC’s 60 50 40 30 Class A Mishaps/100,000 Flight Hours 20 2.39 10 0 50 65 80 96 Fiscal Year

4. All NAVY/MARINE Class A, B, & C Mishaps 16 14 12 Human 10 8 Class A, B,& C Mishaps/100,000 Flight Hours 6 4 Mechanical 2 0 1979 1981 1987 1985 1983 1989 1991 1977 Year Shappell & Wiegmann, 1996

5. Unsafe Acts Active versus Latent Failures (Reason, 1990) • Active Conditions • Failed to Scan Instruments • Penetrated IMC when VMC only Failed or Absent Defenses

6. Active versus Latent Failures (Reason, 1990) • Latent Conditions • Poor CRM • Mental Fatigue Preconditions for Unsafe Acts Unsafe Acts • Active Conditions • Failed to Scan Instruments • Penetrated IMC when VMC only Failed or Absent Defenses

7. Active versus Latent Failures (Reason, 1990) • Latent Conditions • Deficient training program • Improper crew pairing Unsafe Supervision • Latent Conditions • Poor CRM • Mental Fatigue Preconditions for Unsafe Acts Unsafe Acts • Active Conditions • Failed to Scan Instruments • Penetrated IMC when VMC only Failed or Absent Defenses

8. Organizational Factors Active versus Latent Failures (Reason, 1990) • Latent Conditions • Excessive cost cutting • Inadequate promotion policies • Latent Conditions • Deficient training program • Improper crew pairing Unsafe Supervision • Latent Conditions • Poor CRM • Mental Fatigue Preconditions for Unsafe Acts Unsafe Acts • Active Conditions • Failed to Scan Instruments • Penetrated IMC when VMC only Failed or Absent Defenses • Accident & Injury • Crashed into side of • mountain

9. Errors Violations Perceptual Errors Decision Errors Skill-Based Errors Routine Exceptional Unsafe Acts UNSAFE ACTS

10. UNSAFE ACTS Errors Decision Errors Decision Errors DECISION ERROR Unsafe Acts UNSAFE ACTS Errors Violations Perceptual Errors Skill-Based Errors Routine Exceptional • Rule-based Decisions • - If X, then do Y • - Highly Procedural • Choice Decisions • - Knowledge-based • Ill-Structured Decisions • - Problem solving

11. UNSAFE ACTS Errors Decision Errors Skill-Based Errors Skill-Based Errors SKILL-BASED ERRORS Unsafe Acts UNSAFE ACTS Errors Violations Perceptual Errors Routine Exceptional • Attention Failures - Breakdown in visual scan - Inadvertent operation of control - Failure to see and avoid • Memory Failure - Omitted item in checklist - Omitted step in procedure

12. UNSAFE ACTS Errors Decision Errors Skill-Based Errors Perceptual Errors PERCEPTUAL ERRORS Unsafe Acts UNSAFE ACTS Errors Violations Perceptual Errors Routine Exceptional • Misjudge Distance, Altitude, Airspeed • Spatial Disorientation • Visual Illusions

13. UNSAFE ACTS UNSAFE ACTS Violations Violations Decision Errors Skill-Based Errors Routine Routine ROUTINE (INFRACTIONS) (Habitual departures from rules condoned by management) Unsafe Acts Errors Perceptual Errors Exceptional • Violation of Orders/Regulations/SOP • - Failed to Inspect ACFT after In-Flight Caution Light • - Violated Squadron SOP Restricting Flight Below 500’ • - Failed to Comply with NATOPS During Streaming • - Conducted Night Training and Ops Mission with PAX • - Elected to File VFR in Marginal Weather Conditions • - Failed to Use Radar Advisories from ATC • - Inadequate Brief and Limits on Mission • - HAC Knowingly Accepted Non-Current Crew • Failed to Adhere to Brief • Not Current/Qualified for Mission • Improper Procedure

14. UNSAFE ACTS UNSAFE ACTS Violations Violations Decision Errors Skill-Based Errors Exceptional Exceptional EXCEPTIONAL (Isolated departures from the rules not condoned by management) Unsafe Acts Errors Perceptual Errors Routine Exceptional • Violated NATOPS/Regulations/SOP - Performed Unauthorized Acrobatic Maneuver - Canyon Running - Failed to Complete Performance Computations for Flight - Improper Takeoff Technique - Failed to Obtain Valid Weather Brief • Accepted Unnecessary Hazard • Not Current/Qualified for Mission • Exceeded Limits of Aircraft

15. PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts Unsafe Acts

16. PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Adverse Mental States Preconditions for Unsafe Acts ADVERSE MENTAL STATE Unsafe Acts PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement • Loss of Situational Awareness • Circadian dysrhythmia • Alertness (Drowsiness) • Overconfidence • Complacency • Task Fixation

17. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts ADVERSE PHYSIOLOGICAL STATES Unsafe Acts • G-induced Loss of Consciousness • Hypoxia • Motion Sickness • Medical Illness • Intoxication

18. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts PHYSICAL/MENTAL LIMITATIONS Unsafe Acts Physical/ Mental Limitations • Lack of Sensory Input • Limited Reaction Time • Incompatible Physical Capabilities • Incompatible Intelligence/Aptitude

19. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Interpersonal Resource Mismanagement Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts CREW RESOURCE MISMANAGEMENT Unsafe Acts • Not Working as a Team • Poor Aircrew Coordination • Improper Briefing Before a Mission • Inadequate Coordination of Flight

20. PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Personal Readiness Personal Readiness Crew Resource Mismanagement Preconditions for Unsafe Acts PERSONAL READINESS Unsafe Acts Readiness Violations • Crew Rest Requirements • Bottle-to-Brief Rules • Self-Medicating Poor Judgement • Poor Dietary Practices • Overexertion While Off Duty • Excessive “Voluntary” PT

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

22. UNSAFE SUPERVISION UNSAFE SUPERVISION Inadequate Supervision Unsafe Supervision INADEQUATE SUPERVISION Preconditions for Unsafe Acts Unsafe Acts Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision • Failure to Administer Proper Training • Lack of Professional Guidance

23. UNSAFE SUPERVISION Planned Inappropriate Operations Unsafe Supervision PLANNED INAPPROPRIATE OPERATIONS Preconditions for Unsafe Acts Unsafe Acts UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision • Mission Risk without Benefit • Improper Work Tempo • Poor Crew Pairing

24. UNSAFE SUPERVISION Failed to Correct Problem Unsafe Supervision FAILED TO CORRECT A KNOWN PROBLEM Preconditions for Unsafe Acts Unsafe Acts UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision • Failure to Correct Inappropriate Behavior • Failure to Correct a Safety Hazard

25. UNSAFE SUPERVISION Supervisory Violations Supervisory Violations Unsafe Supervision SUPERVISORY VIOLATIONS Preconditions for Unsafe Acts Unsafe Acts UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Inadequate Supervision • Not Adhering to Rules and Regulations • Willful Disregard for Authority by • Supervisors

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

27. ORGANIZATIONAL INFLUENCES ORGANIZATIONAL INFLUENCES Resource Management Resource Management Organizational Climate Operational Process Organizational Influences RESOURCE MANAGEMENT Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts • Human • Monetary • Equipment/Facility

28. ORGANIZATIONAL INFLUENCES ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Organizational Climate Operational Process ORGANIZATIONAL CLIMATE Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts • Structure • Policies • Culture

29. ORGANIZATIONAL INFLUENCES ORGANIZATIONAL INFLUENCES Resource Management Organizational Climate Operational Process Operational Process Organizational Influences OPERATIONAL PROCESS Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts • Operations • Procedures • Oversight

30. ORGANIZATIONAL INFLUENCES Organizational Climate Resource Management Organizational Process UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Inadequate Supervision PRECONDITIONS FOR UNSAFE ACTS PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Interpersonal Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Adverse Mental States Personal Readiness UNSAFE ACTS Errors Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional

31. “Whenever we talk about a pilot who has been killed in a flying accident, we should all keep one thing in mind. He...made a judgment. He believed in it so strongly that he knowingly bet his life on it. That his judgment was faulty is a tragedy,… Every instructor, supervisor, and contemporary who ever spoke to him had the opportunity to influence his judgement, so a little bit of all of us goes with every pilot we lose.” --Anonymous