Title: The DoD Human Factors Analysis and Classification System HFACS
1The DoD Human Factors Analysis and Classification
System (HFACS)
2(No Transcript)
3Reasons Swiss-cheese Model of Human Error
Failed or Absent Defenses
Adapted from Reason (1990)
4Reasons Swiss-cheese Model of Human Error
Preconditions for Unsafe Acts
Unsafe Acts
Failed or Absent Defenses
Adapted from Reason (1990)
5Reasons Swiss-cheese Model of Human Error
Unsafe Supervision
Preconditions for Unsafe Acts
Unsafe Acts
Failed or Absent Defenses
Adapted from Reason (1990)
6Reasons Swiss-cheese Model of Human Error
Unsafe Supervision
Preconditions for Unsafe Acts
Unsafe Acts
Failed or Absent Defenses
Accident Injury
Adapted from Reason (1990)
7ACTS
Errors
Violations
Misperception Errors
Judgment and Decision Errors
Skill-Based Errors
8ACTS
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
9SKILL-BASED ERRORS
- Inadvertent Operation
- Checklist Error
- Procedural Error
- Overcontrol/Undercontrol
- Breakdown in Visual Scan
- Inadequate Anti-G Straining Maneuver
10ACTS
Errors
Violations
Misperception Errors
Judgment and Decision Errors
Skill-Based Errors
MISPERCEPTION ERRORS (due to)
- Misjudge Distance, Altitude, Airspeed
- Spatial Disorientation
- Visual Illusions
11ACTS
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
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13Environmental 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
14Environmental 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
15PRECONDITIONS
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
16PRECONDITIONS
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
17PRECONDITIONS
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
18PRECONDITIONS
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
19PRECONDITIONS
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
20PRECONDITIONS
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
21PRECONDITIONS
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
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23SUPERVISION
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
24PLANNED 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
25FAILED TO CORRECT A KNOWN PROBLEM
- Personnel Management
- Operations Management
26- Supervision Discipline Enforcement
- Supervision De Facto Policy
- Directed Violation
- Currency
27Resource/Acquisition Management
Organizational Climate
Organizational Process
28RESOURCE/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
29ORGANIZATIONAL 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
30ORGANIZATIONAL 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
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32POINT 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