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The DoD Human Factors Analysis and Classification System HFACS

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Visual Illusions. Unsafe. Acts. ACTS. Violations. Errors. Misperception ... Illusions: Kinesthetic/Vestibular/Visual. Misperception of Operational Conditions ... – 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
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3
Reasons Swiss-cheese Model of Human Error
Failed or Absent Defenses
Adapted from Reason (1990)
4
Reasons Swiss-cheese Model of Human Error
Preconditions for Unsafe Acts
Unsafe Acts
Failed or Absent Defenses
Adapted from Reason (1990)
5
Reasons Swiss-cheese Model of Human Error
Unsafe Supervision
Preconditions for Unsafe Acts
Unsafe Acts
Failed or Absent Defenses
Adapted from Reason (1990)
6
Reasons Swiss-cheese Model of Human Error
Unsafe Supervision
Preconditions for Unsafe Acts
Unsafe Acts
Failed or Absent Defenses
Accident Injury
Adapted from Reason (1990)
7
ACTS
Errors
Violations
Misperception Errors
Judgment and Decision Errors
Skill-Based Errors
8
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

9
SKILL-BASED ERRORS
  • Inadvertent Operation
  • Checklist Error
  • Procedural Error
  • Overcontrol/Undercontrol
  • Breakdown in Visual Scan
  • Inadequate Anti-G Straining Maneuver

10
ACTS
Errors
Violations
Misperception Errors
Judgment and Decision Errors
Skill-Based Errors
MISPERCEPTION ERRORS (due to)
  • Misjudge Distance, Altitude, Airspeed
  • Spatial Disorientation
  • Visual Illusions

11
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

12
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13
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

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
  • Seating and Restraints
  • Instrument and Sensory Feedback
  • Visibility Restrictions
  • Controls and Switches
  • Automation
  • Personal Equipment Interference
  • Communications - Equipment

15
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

16
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

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
Perceptual Factors
Physical/ Mental Limitations
COGNITIVE FACTORS
  • Inattention
  • Channelized Attention
  • Cognitive Task Oversaturation
  • Confusion
  • Negative Transfer
  • Distraction
  • Geographic Misorientation (Lost)
  • Checklist Interference

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
PSYCHO-BEHAVIORAL
  • Pre-Existing Personality Disorder
  • Pre-Existing Psychological Disorder
  • Emotional State
  • Personality Style
  • Overconfidence
  • Complacency
  • Get-Home-Itis/Get-There-Itis
  • Overaggressive

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
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

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
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

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

22
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23
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

24
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

25
FAILED TO CORRECT A KNOWN PROBLEM
  • Personnel Management
  • Operations Management

26
  • Supervision Discipline Enforcement
  • Supervision De Facto Policy
  • Directed Violation
  • Currency

27
Resource/Acquisition Management
Organizational Climate
Organizational Process
28
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

29
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

30
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

31
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32
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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