Human Factors Analysis

and Classification System

(HFACS)
Organizational
Factors Dr. Shoeb Ahmed Ilyas
Ruby Med Plus
Unsafe
Supervision
Pre-
Conditions
for
Unsafe
Acts
Unsafe
Acts

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 Swiss Cheese Model

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 UNSAFE
ACTS

Errors Violations

Skill-based Decision Perceptual

Routine Exceptional
Errors Errors Errors

Unsaf
e
Acts

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 PRECONDITIONS
FOR
UNSAFE ACTS

Substandard Substandard
Conditions of Practices of
Operators Operators

Adverse Physical/ Crew Non-Supervisory

Adverse Personal
Physiological Mental Resource Tolerance of
Mental States Readiness
States Limitations Management Unsafe Acts

Preconditions
for
Unsafe Acts

Unsafe
Acts

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 UNSAFE
SUPERVISION

Unforeseen Known

Unrecognized Inadequate Planned Failure to

Inadequate Supervisory
Hazardous Documentation/ Inappropriate Correct
Supervision Violations
Operations Procedures Operations Problem

Unsafe
Supervision

Preconditions
for
Unsafe Acts

Unsafe
Acts

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 ORGANIZATIONAL
INFLUENCES

Resource Organizational Operational

Management Climate Process

Organizational
Influences

Unsafe
Supervision

Preconditions
for
Unsafe Acts

Unsafe
Acts

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 Human Factors Analysis
Provides More than just an
Accident Investigation Tool
Organizational
Factors
Opportunity for
Pro-active Action
Unsafe
Supervision by Management

Preconditions
for
Unsafe Acts

Unsafe
Acts
Failures in your
System’s Defenses

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