THE HUMAN FACTORS ANALYSIS AND

CLASSIFICATION SYSTEM (HFACS)

Douglas Wiegmann, Ph.D. Scott Shappell, Ph.D.

University
Shappell & Wiegmann, of
2002 Illinois Civil Aerospace Medical Institute
Shappell & Wiegmann, 2002
 Scheduled Air Carrier U.S. General Aviation
50
50

Accidents/100,000 flight hours

40
40

30 30

20 20

10
10

0
0

1950

1960

1970

1980

1990

2000
1960

1970

1980

1990
Source: Boeing Source: NTSB

U.S. Navy/Marine Corps U.S. Air Force

60 40
Accidents/100,000 flight hours

Accidents/100,000 flight hours

50
30
40

30 20

20
10
10

0 0
1950

1960

1970

1980

1990

2000

1950

1960

1970

1980

1990

2000
Source: U.S. Naval Safety Center Source: U.S. Air Force Safety Center
Shappell & Wiegmann, 2002
 REASONS FOR CONCERN
¾ The rate of improvement has slowed significantly and
substantially during the last 25 years.
Š This has led some to conclude that further
reductions in accident rates are improbable, if
not impossible.

Shappell & Wiegmann, 2002

 REASONS FOR CONCERN
¾ The rate of improvement has slowed significantly and
substantially during the last 10 years.
Š This has led some to conclude that further
reductions in accident rates are improbable, if not
impossible.

¾ Still, aircraft are becoming increasingly expensive

raising the cost of aviation accidents.

Shappell & Wiegmann, 2002

 COST OF ACCIDENTS
U.S. Navy and Marine Corps
FY96-00

Aviation
Recreation
$3.3B $67M

PMV
$129M

Shipboard
Shore/Ground $277M
Total:$3.9 Billion $150M
Shappell & Wiegmann, 2000 Source:
Source: U.S.
U.S. Naval
Naval Safety
Safety Center
Center
 U.S. Navy/Marine Corps (1950-2000)

60

50
Accidents/100,000 flight hours

40

30

20

10

0
1950

1960

1970

1980

1990

2000
Source: U.S. Naval Safety Center

Shappell & Wiegmann, 2002

 All NAVY/MARINE Class A, B, & C Mishaps
16
Class A, B,& C Mishaps/100,000 Flight Hours
14

12
Human
10

2 Mechanical

0
1979

1981

1987
1985
1983

1989

1991
1977

Year
Shappell, S. and Wiegmann, D. (1996). U.S. Naval aviation mishaps 1977-1992: Differences between single and dual-
piloted aircraft. Aviation, Space, and Environmental Medicine, 67, 65-69.
Shappell & Wiegmann, 2002
 Research Sponsors
- FAA, DoD, NASA, & airplane
Effective manufacturers provide
Intervention Data-Driven research funding.
and Prevention Research - Research programs are needs-
Prevention

Programs based and data-driven.

Interventions are therefore
Mitigation very effective.

Mechanical Accident Accident Database

Failure Investigation Database Analysis

- Highly sophisticated - Designed around - Traditional

- Catastrophic failures techniques and traditional analyses are
are infrequent procedures categories clearly outlined
events and readily
- Information is - Variables are well- performed.
- When failures do objective and defined and
occur, they are often quantifiable causally related - Frequent analyses
less severe or help identify
hazardous due to - Effective at - Organization and common
effective determining why the structure facilitate mechanical and
intervention failure occurred access and use engineering
programs. safety issues.

Feedback

Wiegmann, D. & Shappell, S. (2001). Human error analysis of commercial aviation accidents: Application of the Human
Factors Analysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine,72, 1006-1016.
Shappell & Wiegmann, 2002
 Research Sponsors
- FAA, DoD, NASA, & Airlines
Ineffective provide funding for safety
Intervention Fad-Driven research programs.
and Prevention Research - Lack of good data leads to
Prevention

Programs research programs based

primarily on interests and
intuitions. Interventions are
therefore less effective.
Mitigation

Human Accident Accident Database

Error Investigation Database Analysis

- Less sophisticated - Not designed - Traditional human

- Errors occur techniques and around any factors analyses
frequently and are procedures particular human are onerous due
the major cause of error framework to ill-defined
accidents. - Information is variables and
qualitative and - Variables often ill- database
- Few safety programs illusive defined
are effective at structures.
preventing the - Focus on “what” - Organization and - Few analyses have
occurrence or happened but not structure difficult been performed
consequences of “why” it happened to understand to identify
these errors. underlying
human factors
safety issues.

Feedback

Wiegmann, D. & Shappell, S. (2001). Human error analysis of commercial aviation accidents: Application of the Human
Factors Analysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine,72, 1006-1016.
Shappell & Wiegmann, 2002
 ADDRESSING THE PROBLEM
¾ What was required, therefore, was a general
human error framework around which accident
investigation and prevention programs can be
developed.
¾ We explored several approaches and “off-the-
shelf” frameworks
Š Cognitive
Š Ergonomics
Š Aeromedical
Š Psychosocial
Š Organizational
Shappell, S. and Wiegmann, D. Controlled flight into terrain: The utility of an information processing approach to mishap
causal factors. Proceedings of the Eighth Symposium for Aviation Psychology, Ohio State University, 1300-1306, 1995.
Wiegmann, D and Shappell, S. Human factors in U.S. Naval aviation mishaps: An information processing approach.
Proceedings of the Eighth Symposium for Aviation Psychology, Ohio State University, 1995.
Wiegmann, D. and Shappell, S. Human factors analyses of post-accident data: Applying theoretical taxonomies of human
error. International Journal of Aviation Psychology, 7, 67-81, 1997.
Wiegmann, D. and Shappell, S. Human error perspectives in aviation. International Journal of Aviation Psychology, 11, 341-
357, 2001.
Shappell & Wiegmann, 2002
 The Human Factors Analysis and Classification
System (HFACS)

Shappell, S. and Wiegmann, D. A human error approach to accident investigation: The Taxonomy of Unsafe Operations. International
Journal of Aviation Psychology, 7, 269-291, 1998.
Shappell, S. and Wiegmann, D. Human factors analysis of aviation accident data: Developing a needs-based, data-driven, safety program.
Proceedings of the HESSD, Brussels, Belgium, 1999.
Shappell, S. and Wiegmann, D. The Human Factors Analysis and Classification System – HFACS. Office of Aviation Medicine Technical
Report No. DOT/FAA/AM-00/7. Civil Aeromedical Institute, Oklahoma City, OK 73125, 2000.
Shappell, S. and Wiegmann, D. Beyond Reason: Defining the holes in the Swiss Cheese. Human Factors in Aviation Safety, (in press), 2000.

Shappell & Wiegmann, 2002

 Breakdown of a Productive System

Unsafe Active Conditions

Acts
Š Failed to scan instruments
Š Penetrated IMC when VFR only
Failed or
Absent Defenses

Adapted from Reason (1990)

Shappell & Wiegmann, 2002

 Breakdown of a Productive System

Preconditions Active and Latent Conditions

for Š Poor CRM
Unsafe Acts Š Loss of situational awareness

Unsafe Active Conditions

Acts
Š Failed to scan instruments
Š Penetrated IMC when VFR only
Failed or
Absent Defenses

Adapted from Reason (1990)

Shappell & Wiegmann, 2002

 Breakdown of a Productive System

Unsafe Latent Conditions

Supervision Š Deficient training program
Š Improper crew pairing

Preconditions Active and Latent Conditions

for Š Poor CRM
Unsafe Acts Š Loss of situational awareness

Unsafe Active Conditions

Acts
Š Failed to scan instruments
Š Penetrated IMC when VFR only
Failed or
Absent Defenses

Adapted from Reason (1990)

Shappell & Wiegmann, 2002

 Breakdown of a Productive System

Latent Conditions
Inputs Organizational
Factors Š Excessive cost cutting
Š Economic
inflation Š Inadequate promotion policies

Š Few qualified Unsafe Latent Conditions

pilots
Supervision Š Deficient training program
Š Improper crew pairing

Preconditions Active and Latent Conditions

for Š Poor CRM
Unsafe Acts Š Loss of situational awareness

Unsafe Active Conditions

Acts
Š Failed to scan instruments
Š Penetrated IMC when VFR only
Failed or
Absent Defenses
Accident & Injury
Š Crashed into side of
mountain

Adapted from Reason (1990)

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
ACTS
ACTS

Errors
Errors Violations

Decision Skill-Based Perceptual

Routine Exceptional
Errors Errors Errors

Unsafe
Acts

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
ACTS
ACTS

Errors
Errors Violations

Decision Skill-Based Perceptual

Routine Exceptional
Errors Errors Errors

DECISION ERRORS
¾ Rule-based Decisions
Unsafe - If X, then do Y
Acts - Highly Procedural
¾ Choice Decisions
- Knowledge-based
¾ Ill-Structured Decisions
- Problem solving

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
ACTS
ACTS

Errors Violations
Errors

Decision Skill-Based Perceptual

Routine Exceptional
Errors Errors Errors

SKILL-BASED
ERRORS
Unsafe
Acts ¾ Attention Failures
- Breakdown in visual scan
- Inadvertent operation of control
¾ Memory Failure
- Omitted item in checklist
- Omitted step in procedure
¾ Stick-and-Rudder Skills

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
ACTS
ACTS

Errors Violations
Errors

Decision Skill-Based Perceptual

Routine Exceptional
Errors Errors Errors

PERCEPTUAL
Unsafe ERRORS
Acts (due to)
¾ Misjudge Distance,
Altitude, Airspeed
¾ Spatial Disorientation
¾ Visual Illusions

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
ACTS
ACTS

Errors Violations
Errors

Decision Skill-Based Perceptual

Routine Exceptional
Errors Errors Errors

ROUTINE (INFRACTIONS)
(Habitual departures from rules condoned by management)

¾ VFR Flight into IMC

¾ Elected to File VFR in Marginal Weather Conditions
Unsafe ¾ Failed to Use Radar Advisories from ATC
Acts ¾ Inadequate Brief and Limits on Mission
¾IFR Procedure Not Followed
¾Weight and Balance Exceeded
¾Procedure/Directives Not Followed
¾Operating With Known Deficiencies
¾Min. Descent Altitude not Complied with

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
ACTS
ACTS

Errors Violations
Errors

Decision Skill-Based Perceptual

Routine Exceptional
Errors Errors Errors

EXCEPTIONAL
(Isolated departures from the rules not condoned
by management)

Unsafe ¾ Violated NATOPS/Regulations/SOP

Acts - Performed Unauthorized Acrobatic Maneuver
- Canyon Running
- Failed to Complete Performance Computations for Flight
- Failed to Obtain Valid Weather Brief
¾ Accepted Unnecessary Hazard
¾ Not Current/Qualified for Mission
¾ Exceeded Limits of Aircraft

Shappell & Wiegmann, 2002

 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts

Unsafe
Acts

Shappell & Wiegmann, 2002

 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts
ADVERSE MENTAL STATE
Unsafe
Acts ¾ Loss of Situational Awareness
¾ Circadian dysrhythmia
¾ Alertness (Drowsiness)
¾ Overconfidence
¾ Complacency
¾ Task Fixation

Shappell & Wiegmann, 2002

 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts
ADVERSE PHYSIOLOGICAL
Unsafe STATES
Acts
¾ Spatial Disorientation
¾ Visual Illusions
¾ G-induced Loss of Consciousness
¾ Hypoxia
¾ Medical Illness

Shappell & Wiegmann, 2002

 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts
PHYSICAL/MENTAL
Unsafe LIMITATIONS
Acts
¾ Lack of Sensory Input
¾ Limited Reaction Time
¾ Incompatible Physical Capabilities
¾ Incompatible Intelligence/Aptitude

Shappell & Wiegmann, 2002

 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts
CREW RESOURCE
Unsafe MANAGEMENT
Acts
¾ Not Working as a Team
¾ Poor Aircrew Coordination
¾ Improper Briefing Before a Mission
¾ Inadequate Coordination of Flight

Shappell & Wiegmann, 2002

 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts PERSONAL READINESS
Unsafe Readiness Violations
Acts ¾ Crew Rest Requirements
¾ Bottle-to-Brief Rules
¾ Self-Medicating
Poor Judgement
¾ Poor Dietary Practices
¾ Overexertion While Off Duty

Shappell & Wiegmann, 2002

 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts PHYSICAL ENVIRONMENT
Unsafe ¾ Weather
Acts ¾ Lighting
¾ Noise
¾ Heat
¾ Acceleration
¾ Vibration
¾ Pollutants

Shappell & Wiegmann, 2002

 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts TECHNOLOGICAL
Unsafe
ENVIRONMENT
Acts
¾ Equipment and controls
¾ Automation reliability/complexity
¾ Task and Procedure Design
¾ Manuals and Checklist Design
¾ Interfaces and Displays

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem

Unsafe
Supervision

Preconditions
for
Unsafe Acts

Unsafe
Acts

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem

Unsafe
Supervision
INADEQUATE SUPERVISION
¾ Failure to Administer Proper Training
Preconditions
¾ Lack of Professional Guidance
for
Unsafe Acts

Unsafe
Acts

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem

Unsafe
Supervision PLANNED INAPPROPRIATE
OPERATIONS
Preconditions ¾ Mission Risk without Benefit
for
Unsafe Acts ¾ Improper Work Tempo
¾ Poor Crew Pairing
Unsafe
Acts

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem

Unsafe
Supervision FAILED TO CORRECT A
KNOWN PROBLEM
Preconditions ¾ Failure to Correct Inappropriate Behavior
for
¾ Failure to Correct a Safety Hazard
Unsafe Acts

Unsafe
Acts

Shappell & Wiegmann, 2002

 UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem

Unsafe
Supervision
SUPERVISORY VIOLATIONS
Preconditions ¾ Not Adhering to Rules and Regulations
for ¾ Willful Disregard for Authority by
Unsafe Acts Supervisors

Unsafe
Acts

Shappell & Wiegmann, 2002

 ORGANIZATIONAL
INFLUENCES

Resource
Resource Organizational Operational
Management
Management Climate Process

Organizational
Influences

Unsafe
Supervision

Preconditions
for
Unsafe Acts

Unsafe
Acts

Shappell & Wiegmann, 2002

 ORGANIZATIONAL
INFLUENCES

Resource
Resource Organizational Operational
Management
Management Climate Process

Organizational
Influences RESOURCE MANAGEMENT
¾ Human
Unsafe
Supervision
¾ Monetary
¾ Equipment/Facility

Preconditions
for
Unsafe Acts

Unsafe
Acts

Shappell & Wiegmann, 2002

 ORGANIZATIONAL
INFLUENCES

Resource
Resource Organizational Operational
Management
Management Climate Process

Organizational ORGANIZATIONAL
Influences
CLIMATE
Unsafe ¾ Structure
Supervision
¾ Policies
¾ Culture
Preconditions
for
Unsafe Acts

Unsafe
Acts

Shappell & Wiegmann, 2002

 ORGANIZATIONAL
INFLUENCES

Resource
Resource Organizational Operational
Management
Management Climate Process

Organizational
Influences OPERATIONAL
PROCESS
Unsafe
Supervision ¾ Operations
¾ Procedures
Preconditions ¾ Oversight
for
Unsafe Acts

Unsafe
Acts

Shappell & Wiegmann, 2002

 ORGANIZATIONAL
INFLUENCES

Resource Organizational Organizational

Management Climate Process

UNSAFE
SUPERVISION

Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem

PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Management Readiness
Adverse Adverse Physical/
Mental Physiological Mental
States States Limitations

UNSAFE
ACTS

Errors Violations

Decision Skill-Based Perceptual

Routine Exceptional
Errors Errors Errors
Shappell & Wiegmann, 2002
Shappell & Wiegmann, 2002
 Intervention: Filling the Holes in the Cheese
Organizational
Safe
Decisions
Factors

Unsafe
Safe
Supervision

Preconditions
Preconditions
for
Safe Acts
Unsafe Acts

Unsafe
Safe
Acts

Shappell & Wiegmann, 2002

 U.S. NAVY/MARINE CORPS

AVIATION ACCIDENT DATA

Shappell, S. and Wiegmann, D. Is proficiency eroding among U.S. Naval aircrews? A quantitative analysis using the
Human Factors Analysis and Classification System. Proceedings of the 44th Annual Meeting of the Human Factors
and Ergonomics Society,
Society, San Diego, California, 2000.
Shappell, S., Squier,
Squier, H., Abad,
Abad, G., and Wiegmann, D. An analysis of U.S. Navy and Marine Corps mishaps using the
failure analysis classification system: Implications for prevention.
prevention. 69th Annual Meeting of the Aerospace Medical
Association,
Association, 1998.
Shappell, S., Wiegmann, D., Fraser, J., Gregory, G., Kinsey, P., and Squier,
Squier, H. Beyond mishap rates: A human factors
analysis of U.S. Navy/Marine Corps TACAIR and Rotary Wing mishaps mishaps using HFACS. 70th70th Annual Meeting of the
Aerospace Medical Association,
Association, 1999.
Shappell, S., Wiegmann, D., Fraser, J., Tanner, G., Kinsey, P., and Reddix,
Reddix, M. Tracking aircrew error trends in Naval
aviation mishaps using HFACS. 71st Annual Meeting of the Aerospace Medical Association,
Association, 2000.
Shappell & Wiegmann, 2002
 Sample of the Types of Human Error Typically Found
Aircraft Control Not Maintained
Procedures/Directives Not Followed
Abort Delayed
Airspeed (VREF) Not Maintained
APU Selected
Proper Touchdown Point Misjudged
Abort Above V1 Improper
Airspeed (VMC) Not Maintained
Autopilot Improper Use Of
Complacency
Control Interference Inadvertent
Crew/Group Coordination Not Maintained
Proper Touchdown Point Not Attained
Airspeed Not Maintained
Airspeed (VR) Improper
Autopilot Inadvertent Deactivation
Circuit Breaker Selected
Compensation for Wind Conditions Not Possible
Flare Improper
Unsafe/Hazardous Condition Not Identified
VFR Flight Into IMC Attempted
Flight Into Adverse Weather Continued
Hydraulic System Not Selected
Inadequate Surveillance of Operation
Proper Touchdown Point Not Possible
Aborted Takeoff Delayed
Airspeed (VLOF) Not Attained
Airspeed Excessive
Altimeter Setting Not Obtained
Altitude Not Maintained
Became Lost/Disoriented
Checklist Not Complied With
Crew/Group Coordination Not Performed
Flaps Improper Use Of
Flare Excessive
Flight into Known Adverse Weather Initialed
Go-Around Not Performed
Identification of Aircraft Visually Delayed
Inadequate Substantiation Process
Visual Separation Not Maintained
Minimum Descent Altitude Not Maintained
Wheels Up Landing Inadvertent
Aircraft Preflight Not Performed
Aircraft Weight and Balance Misjudged
Altimeter Not Used
Checklist Inaccurate
Shappell & Wiegmann, 2002
Compensation For Wind Conditions Inadequate
Descent Excessive
Distance Misjudged
Flare Delayed
Ground Loop/Swerve Intentional
Remedial Action Delayed
VFR Flight Into IMP Initiated
Visual Lookout Not Maintained
Abort Above V1 Performed
Compensation for Wind Conditions Improper
Directional Control Not Maintained
Diverted Attention
Ice/Frost Removal From Aircraft Inadequate
IFR Procedure Improper
Aircraft Control Not Possible
Stall Inadvertent
Inadequate Visual Lookout
Lack of Familiarity With Aircraft
Lack of Total Experience in Type of Aircraft
Lowering of Flaps Performed
Pressure
VFR Flight Into IMC Inadvertent
Aborted Takeoff Performed
Communications Not Understood
Emergency Procedure Not Followed
Inadequate Weather Evaluation
Nosewheel Steering Excessive
Procedure Inadequate
Rotation Excessive
VFR Flight into IMC Continued
Emergency Procedure Not Performed
Lack of Familiarity with Geographic Area
Level Off Not Attained
Maintenance, Adjustment Improper
Monitoring Inadequate
Propeller Feathering Not Performed
Remedial Action Not Possible
Visual/Aural Perception
Preflight Planning/Preparation Inadequate
Aircraft Handling Improper
Crew/Group Coordination Inadequate
Spoiler Extension Not Performed
Stall/Spin Inadvertent
Airspeed (VREF) Not Attained
Airspeed (VS) Not Maintained
Go-Around Delayed
Fatigue (Flight and Ground Schedule)
Flight to Alternation Not Performed
Operation with Known Deficiencies in Equipment
Spoiler Extension Inadvertent Activation
Supervision Inadequate
Planning/Decision improper
Raising of Flaps Improper
In-Flight Planning/Decision Improper
Overconfidence in Personal Ability
Parking Brake Not Set
Expectancy
Flight Manuals Improper Use Of
Wrong Taxi Route Selected
Gear Extension Not Performed
Weather Evaluation Inadequate
Stall/Mush Encountered
Parking Brakes Inadvertent Deactivation
In-Flight Planning/Decision Poor
Proper Glidepath Not Maintained
Altitude Inadequate
Conditions/Steps Insufficiently Defined
Evacuation Improper
Passenger Briefing Inadequate
Spatial Disorientation
Throttle/Power Control Improper Use Of
Weather Evaluation Inaccurate
Wrong Runway Selected
Ice/Frost Removal From Aircraft Not Identified
Planned Approach Poor
Recovery from Bounced Landing Improper
Planning/Decision Inadequate
Aircraft Preflight Inadequate
Checklist Inadequate
Descent Inadvertent
Generator Inadvertent Deactivation
Touchdown Inadvertent
Preflight Planning/Preparation Improper
Compensation for Wind Conditions Misjudged
Visual Illusion
Uncontrolled Descent
Proper Descent Rate Not Maintained
Checklist Not Used
Anti-Ice/Deice System Not Used
Inadequate Monitoring
Powerplant Controls Inadvertent Activation
Traffic Advisory Not Identified
Clearance Misjudged
IFR Procedure Not Followed
Inattentive
Remedial Action Attempted
Someone Goofed
Improper Use of Preflight Briefing Service
Descent Premature
Proper Descent Rate Not Attained
Airspeed Not Maintained (generic)
Inadvertent Stall
Visual Lookout Inadequate
Ice/Frost Removal From Aircraft Nor Performed
Information Insufficient
Self-Induced Pressure
Trim Setting Improper
Flight Controls Improper Use Of
Altitude/Clearance Not Maintained
Maneuver Performed
Preflight Planning/Preparation Poor
Proper Altitude Not Maintained
Flare Initiated
Flight Advisories Not Followed
Altitude/Clearance Inadequate
Distance/Altitude Misjudged
Inadequate Training
Rotation Improper
Unsuitable Terrain or Takeoff/Landing/Taxi Area
VFR Procedures Inadequate
Proper Alignment Not Possible
Remedial Action Improper
Flare Misjudged
Proper Alignment Delayed
Missed Approach Not Performed
Proper Alignment Not Attained
Lack of Total Experience in Type Operation
Minimum Descent Altitude Below
Miscellaneous Equipment Initiated
Proper Alignment Not Maintained
Supervision Improper
Gear Down and Locked Not Verified
Wind Information Misjudged
Aircraft Weight and Balance Exceeded
Aircraft Control-Uncontrolled
Crew/Group Coordination Not Attained
Checklist Not Followed
Clearance Not Maintained
 Number and Percentage of Mishaps Associated with Each
HFACS Causal Category (FY 91-99)
USMC USN
n=73 n=105
Count (%) Count (%)

Organizational Influences
Resource Management 17 (23) 32 (30)
Organizational Climate 0 (0) 1 (1)
Organizational Process 19 (26) 39 (37)

Unsafe Supervision
Inadequate Supervision 18 (25) 27 (26)
Planned Inappropriate Operations 9 (12) 11 (10)
Failed to Correct a Known Problem 4 (5) 10 (10)
Supervisory Violations 8 (11) 11 (10)

Preconditions for Unsafe Acts

Adverse Mental States 57 (78) 79 (75)
Adverse Physiological States 18 (25) 27 (26)
Physical/Mental Limitations 7 (10) 11 (10)
Crew Resource Mismanagement 40 (55) 69 (66)
Personal Readiness 2 (3) 5 (5)

Unsafe Acts
Decision Errors 36 (49) 64 (61)
Skill-based Errors 38 (52) 57 (54)
Perceptual Errors 23 (32) 28 (27)
Shappell & Wiegmann, 2002
Violations 22 (30) 33 (31)
 UNSAFE
UNSAFE
ACTS
ACTS

Errors Violations
Errors

Decision Skill-Based Perceptual

Errors Errors Errors

VIOLATIONS
¾ 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
¾ Failed to Adhere to Brief
¾ Not Current/Qualified for Mission
¾ Improper Procedure

Shappell & Wiegmann, 2002

 Percentage of Human Error Mishaps
Associated with Violations (FY 91-97)
50 ρ=-.487, ns

40
Percentage

30

20

10

0
91 92 93 94 95 96 97 98 99
Fiscal Year
Shappell & Wiegmann, 2002
 Intervention Strategy

¾ Professionalism
¾ Accountability
¾ Enforcing the Rules
Shappell & Wiegmann, 2002
 Percentage of Human Error Mishaps Associated with
Violations (FY 91-99)
50

40
Percentage

30

20

10

0
91 92 93 94 95 96 97 98 99
Fiscal Year
Shappell & Wiegmann, 2002
 UNSAFE
UNSAFE
ACTS
ACTS

Errors Violations
Errors

Decision Skill-Based Perceptual

Routine Exceptional
Errors Errors Errors

SKILL-BASED ERRORS
¾ Breakdown in Visual Scan
Unsafe ¾ Failed to See and Avoid
Acts
¾ Poor Technique
¾ Omitted Checklist Item
¾ Inadvertent Operation of Control
¾ Improper Use of Flight Controls

Shappell & Wiegmann, 2002

 Percentage of Human Error Mishaps Associated with
Skill-based Errors (FY 91-99)
80

70

60
Percentage

50
ρ=.832, p<.01
40

30

20

10

0
91 92 93 94 95 96 97 98 99
Fiscal Year
Shappell & Wiegmann, 2002
 Preliminary Intervention Strategy

¾ Improve instrument scan

¾ Prioritizing attention
¾ Recognizing extremis situations
¾ Refine basic flight skills (Stick-and-Rudder)
¾ Practice procedures
¾ Review the mishap database!
Shappell & Wiegmann, 2002
 PRECONDITIONS
FOR
UNSAFE ACTS

Environmental Personnel
Factors Factors
Condition of
Operators

Physical Technological Crew Resource Personal

Environment Environment Adverse Adverse Physical/ Management Readiness
Mental Physiological Mental
States States Limitations

Preconditions
for
Unsafe Acts
CREW RESOURCE
Unsafe MANAGEMENT
Acts
¾ Not Working as a Team
¾ Poor Aircrew Coordination
¾ Improper Briefing Before a Mission
¾ Inadequate Coordination of Flight

Shappell & Wiegmann, 2002

 Percentage of Human Error Mishaps Associated with
Crew Resource Management Failures (FY 91-98)
80

70
ρ=.551, ns
60
Percentage

50

40

30

20

10

0
91 92 93 94 95 96 97 98 99
Percentages do not add up to 100%
Fiscal Year
Shappell & Wiegmann, 2002
 Preliminary Intervention Strategy

¾ Platform specific training ¾ Change group composition

¾ Use of video feedback ¾ Attempt to change attitudes
¾ Restructure tasks (i.e., EP’s)
Shappell & Wiegmann, 2002 ¾ Additional research...
 Percentage of Human Error Mishaps Associated with
Crew Resource Management Failures (FY 91-99)
80

70

60
Percentage

50

40

30

20

10

0
91 92 93 94 95 96 97 98 99
Percentages do not add up to 100%
Fiscal Year
Shappell & Wiegmann, 2002
 Research Sponsors
- FAA, DoD, NASA, & Airlines
Ineffective
Effective provide funding for safety
Intervention Data-Driven
Fad-Driven research programs.
and Prevention Research - Research
Lack of goodprograms
data leads
are needs-
to
Prevention

Programs research
based andprograms
data-driven.
based
primarily on interests
Interventions are therefore
and
intuitions.
very effective.
Interventions are
therefore less effective.
Mitigation

Human Accident Accident Database

Error Investigation Database Analysis

--Less sophisticated
Sophisticated - Designed
Not designed
around a - Traditional human
- Errors occur less techniques factors analyses
techniquesand
and around any human
well-known
frequently and are
frequently. procedures particular
error framework
human are onerous due
much less
procedures
the major cause of error framework to ill-defined
onerous due to
- Safety programs are
accidents. --Information
Informationisis - Well-defined variables and
well-defined
effective at qualitative
qualitativeand
and - Variables
variables often ill- database and
variables
- Few
preventing
safety programs
the illusive defined
quantitative structures.
error database
are effectiveorat
occurrence - Organization and
preventing theof
consequences --Focus
Focuson
on“what”
both structure easyand
- Organization to Few analyses
- Analyses have
can now
occurrence
these errors.or happened but not
“what” happened understand
structure difficult been
be performed
performed to
consequences of “why” it happened
and “why” to understand to identify
identify human
these errors. underlying
HFACS factors safety
human factors
issues
ORGANIZATIONAL
INFLUENCES
safety issues.
Resource Organizational Organizational
Management Climate Process

UNSAFE
SUPERVISION

Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem

PRECONDITIONS
FOR

Feedback
UNSAFE ACTS

Environmental
Factors
Condition of
Personnel
Factors
Feedback
Operators

Physical Technological Crew Resource Personal

Environment Environment Management Readiness
Adverse Adverse Physical/
Mental Physiological Mental
States States Limitations

UNSAFE
ACTS

Errors Violations

Decision Skill-Based Perceptual

Routine Exceptional

Shappell & Wiegmann, 2002

Errors Errors Errors
Shappell & Wiegmann, 2002
 HFACS can be applied anywhere!

Flightdeck Maintenance
(HFACS) (HFACS-ME)

? ATC
(HFACS-ATC)

Shappell & Wiegmann, 2002