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The DoD Human Factors Analysis and Classification System HFACS

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Developed at the Navy Safety Center in the late 1980's. Based on various theories of human error ... Rank/Position Authority Gradient. Communicating Critical ... – PowerPoint PPT presentation

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Title: 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 Ws)
  • What Happen ?
  • Why it Happened ?
  • What to do to prevent it ?

4
HFACS Background
  • Developed at the Navy Safety Center in the late
    1980s
  • 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

5
HFACS Benefits
  • Structured analysis of human error
  • Sophisticated, completeyet 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

6
HFACS Tiers
Latent Failures/Conditions
Supervision
Preconditions
Acts
Active Failures
Deficient or Immature Conditions
Accident Injury
Adapted from Reason (1990)
7
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8
ACTS
Errors
Violations
Misperception Errors
Judgment and Decision Errors
Skill-Based Errors
9
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
SKILL-BASED ERRORS
  • Inadvertent Operation
  • Checklist Error
  • Procedural Error
  • Overcontrol/Undercontrol
  • Breakdown in Visual Scan
  • Inadequate Anti-G Straining Maneuver

11
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
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
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14
Environmental Factors
Personnel Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Coordination/ Communication/ Planning Factors
Condition of Individuals
Adverse Physiological States
Cognitive Factors
Psycho-Behavioral Factors
Perceptual Factors
Physical/ Mental Limitations
  • 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
Environmental Factors
Personnel Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Coordination/ Communication/ Planning Factors
Condition of Individuals
Adverse Physiological States
Cognitive Factors
Psycho-Behavioral Factors
Perceptual Factors
Physical/ Mental Limitations
  • Seating and Restraints
  • Instrument and Sensory Feedback
  • Visibility Restrictions
  • Controls and Switches
  • Automation
  • Personal Equipment Interference
  • Communications - Equipment

16
PRECONDITIONS
Environmental Factors
Personnel Factors
Technological Environment
Physical 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
Environmental Factors
Personnel Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Coordination/ Communication/ Planning Factors
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
Environmental Factors
Personnel Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Coordination/ Communication/ Planning Factors
Condition of Individuals
Adverse Physiological States
Cognitive Factors
Psycho-Behavioral Factors
Perceptual Factors
Physical/ Mental Limitations
COGNITIVE FACTORS
  • Inattention
  • Channelized Attention
  • Cognitive Task Oversaturation
  • Confusion
  • Negative Transfer
  • Distraction
  • Geographic Misorientation (Lost)
  • Checklist Interference

19
PRECONDITIONS
Environmental Factors
Personnel Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Coordination/ Communication/ Planning Factors
Condition of Individuals
Adverse Physiological States
Cognitive Factors
Psycho-Behavioral Factors
Perceptual Factors
Physical/ Mental Limitations
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
Environmental Factors
Personnel Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Coordination/ Communication/ Planning Factors
Condition of Individuals
Adverse Physiological States
Cognitive Factors
Perceptual Factors
Physical/ Mental Limitations
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
Environmental Factors
Personnel Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Coordination/ Communication/ Planning Factors
Condition of Individuals
Adverse Physiological States
Cognitive Factors
Psycho-Behavioral Factors
Perceptual Factors
Physical/ Mental Limitations
PHYSICAL/MENTAL LIMITS
  • Learning Ability/Rate
  • Memory Ability/Lapses
  • Anthropometric/Biomechanical Limits
  • Motor Skill/Coordination or Timing Deficiency
  • Technical/Procedural Knowledge

22
PRECONDITIONS
Environmental Factors
Personnel Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Coordination/ Communication/ Planning Factors
Condition of Individuals
Adverse Physiological States
Cognitive Factors
Psycho-Behavioral Factors
Perceptual Factors
Physical/ Mental Limitations
PERCEPTUAL FACTORS
  • Illusions Kinesthetic/Vestibular/Visual
  • Misperception of Operational Conditions
  • Misinterpreted/Misread Instrument
  • Expectancy
  • Auditory Cues
  • Spatial Disorientation 1, 2, 3
  • Temporal Distortion

23
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24
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
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
FAILED TO CORRECT A KNOWN PROBLEM
  • Personnel Management
  • Operations Management

27
  • Supervision Discipline Enforcement
  • Supervision De Facto Policy
  • Directed Violation
  • Currency

28
Resource/Acquisition Management
Organizational Climate
Organizational Process
29
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
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
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
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33
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34
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35
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36
Night Watch - 150
37
Night Watch - 150
38
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

39
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.

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
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

42
Case Scenario I
43
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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
Brkdwn vis scan
Commm Critical Information
47
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_at_uscg.mil
  • http//www.uscg.mil/safety
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