HUMAN FACTOR ANALYSIS AND

CLASSIFICATION SYSTEM

DY COMDT
RS PUNDIR
 WAY POINTS
INTRODUCTION
NEED FOR HFACS
REASON’S SWISS CHEESE MODEL
HFACS GUIDING PRINCIPLES
HOW TO USE HFACS WORKSHEET
HFACS FLOW CHART
SUBCODES AND NANO CODES
SUMMARY
CONCLUSION
QUESTION
 INTRODUCTION

DR. SCOTT SHAPPELL AND DR. DOUG WIEGMANN

INCREASING NO OF ACCIDENTS IN 1980-90 IN US

NAVY, AIR FORCE AND MARINE

JAMES REASON’S SWISS CHEESE MODEL

“HUMAN BEINGS BY THEIR VERY NATURE MAKE MISTAKES;

THEREFORE, IT IS UNREASONABLE TO EXPECT ERROR-FREE
HUMAN PERFORMANCE.” SHAPPELL & WIEGMANN, 1997
 NEED FOR HFACS
FIRST FLIGHT IN 1903.
IMPROVEMENT IN MACHINERY
/ TECHNOLOGY
HUMAN ERROR CONTRIBUTES
TO 70-80 %
NEED BASE, DATA DRIVEN
SAFETY PROGRAM
 REASON’S “SWISS-CHEESE”
MODEL
INPUTS ORGANIZATIONA
L LATENT FAILURES /
FACTORS CONDITIONS
UNSAFE
SUPERVISION

PRECONDITION ACTIVE & LATENT

S FAILURES / CONDITION
FOR
UNSAFE ACTS
UNSAF
E
ACTS ACTIVE
FAILED OR FAILURES /
ABSENT CONDITIONS
DEFENSES
ACCIDENT &
INJURY

MISHAP
 WHERE DO COMMANDERS AND
OTHERS USUALLY LOOK TO PREVENT
MISHAPS?

OPERATORS
UNSAF
E
ACTS

MISHA
P
 HFACS GUIDING PRINCIPLES

PRINCIPLE 1: AVIATION IS A COMPLEX SYSTEMS.

PRINCIPLE 2: HUMAN ERRORS ARE INEVITABLE WITHIN

SUCH A SYSTEM.
PRINCIPLE 3: BLAMING AN ERROR ON THE SERVICE
MEMBER IS LIKE BLAMING A MECHANICAL FAILURE ON
THE EQUIPMENT.
PRINCIPLE 4: A MISHAP, NO MATTER HOW MINOR, IS A
FAILURE OF THE SYSTEM.
PRINCIPLE 5: MISHAP INVESTIGATION AND ERROR
PREVENTION (AKA: RISK MANAGEMENT).
 ORGANIZATIONAL
INFLUENCES

Resource/ Organisational Organisational

Acquistion Climate Processes
Problems
UNSAFE
SUPERVISION

Inadequate Planned Inappropriate Failure to correct Supervisory

Supervision Operations known problem Violations

PRECONDITIONS

Environmental Personnel
Factors Factors
Condition of
Physical Technological Individuals
Teamwork Self-
Environment Environment Imposed
Stress

Cognitive Psycho Behavioral Adverse Physical/ Mental Perceptual

Physiological limit

UNSAFE
ACTS

Errors Violations

Skill based Judgment & Decision- Perception based

Making Errors
HOW TO USE HFACS WORKSHEET
THERE ARE TOTAL 04 SECTIONS, 24 SUB CODES WHICH
ARE DIVIDED IN 147 STATEMENTS AND EACH STATEMENT
IS TO BE RATED ON A 4 POINT SCALE, WHERE
4 - PRIMARY CAUSE

3 - SECONDARY CAUSE

2 - FACTOR WAS PRESENT BUT DIDN'T AFFECT THE

OUTCOME AT ALL, WAS NOT CONTRIBUTORY

1 - FACTOR WAS NOT PRESENT

IT IS MANDATORY TO RATE EACH STATEMENT
 UNSAFE 80%
ACTS

Errors Violation
s

Skill-based Decisio Perceptua

Errors n l
Errors Errors

Unsaf
e
Acts
 UNSAFE
ACTS

Errors Violation
s

Skill-Based
Decision Decisio Perceptua
Errors n l
Error Errors

SKILL-BASED
Unsaf ERROR
e Inadvertent Operation
Acts Checklist Error
Procedural Error
Over Control/ Under Control
Breakdown in Visual Scan
Inadequate Anti-'G' Straining
Maneuver
 UNSAFE
ACTS

Errors Violation
s

Skill-based Skill-Based
Decisio Perceptua
Errors Errors
n l
Errors Errors

DECISION ERRORS
Unsaf
e Risk Assessment - During Operation
Acts Task Misprioritisation
Necessary Action- Rushed
Necessary Action- Delayed
Caution/ Warning- Ignored
Decision- Making During Operation
 UNSAFE
ACTS

Errors Violation
s

Skill-Based Decision Perceptua

Errors Error l
Errors

PERCEPTUAL ERRORS
Unsaf
e Errors Due to Misperception
Acts Ex. Missjudge Distance,
Altitude, Airspeed,
Groundspeed, Azimuth,
Spatial
Disorientation, Visual Illusions
 UNSAFE
ACTS

Errors Violations
Violations

Skill-Based Decisio Perceptua

Errors n l
Errors Errors

Violation
Violations Routine/ Widespread
Violation Based On Risk
Assessment
Violation - Lack of Discipline
Unsaf
e
Acts
 PRECONDITION
S
FOR
UNSAFE ACTS

Environment Condition Personal

al of Individual Factor
Factors

Physical Technical Cognitiv Psycho Adverse

Environmen Physiologi
Environmen e Behaviou
t cal Coordinati
t Factors ral
State on/
Precondition Physical Planning
s
/ Failure
for
Unsafe Acts
Physical Environment Mental Self
Physical Environment
Unsaf Vision Restricted by Icing Limitati Imposed
e Perceptu
Acts
Vision restricted met condition on Stress
Vibration al
Vision restricted workspace
Windblast Factors
Thermal stress cold
Thermal Stress Heat
Manoeuvring force in flight
Lighting of other Aircrafts/ Vehicle
Noise interference
Brownout/ Whiteout
 PRECONDITION
S
FOR
UNSAFE ACTS

Environment Condition Personal

al of Individual Factor
Factors

Physical Technical Cognitiv Psycho Adverse

Environmen Physiologi
Environmen e Behaviou
t cal Coordinati
t Factors ral
State on/
Precondition Physical Planning
s
/ Failure
for
Unsafe Acts Mental Self
Unsaf Technical Environment Limitati Imposed
e Perceptu
Acts Seating and restraints on Stress
Instrument and sensory feedback al
Visibility restriction Factors
Control and switches
Automation
Workspace Incompatible with human
Personal equipment interference
Communication equipment
 PRECONDITION
S
FOR
UNSAFE ACTS

Environmen Condition Personal

of Individual
tal Factor
Factors

Physical Technical Cognitiv Psycho Adverse

e Physiologi
Environmen Environmen Behaviou
Factors cal Coordinati
t t ral
State on/
Precondition Physical Planning
s
/ Failure
for
Unsafe Acts Mental Self
Unsaf Cognitive Factors Limitati Imposed
e Perceptu
Acts Inattention on Stress
Channelized attention al
Cognitive task oversaturation Factors
Confusion
Negative transfer
Distraction
Geographic Misorientation (lost)
Checklist interference
 PRECONDITION
S
FOR
UNSAFE ACTS

Environmen Condition Personal

of Individual
tal Factor
Factors

Physical Technical Cognitiv Psycho Adverse

Environmen Environmen e Behaviou Physiologi
ral cal Coordinati
t t Factors
State on/
Precondition Psycho Behavioural Physical Planning
s Pre existing personality disorder
/ Failure
for Pre existing psychological disorder
Unsafe Acts Pre existing psychological problem Mental Self
Emotional state
Unsaf
Personality style Limitati Imposed
e Perceptu
Acts Overconfidence on Stress
Pushing beyond limits al
Complacency
Inadequate Motivation Factors
Misplaced Motivation
Overaggressive motivation to succeed
Excessive motivation to succeed
Get home itis/ get there itis
Response set
Motivational Exhaustion
 PRECONDITION
S
FOR
UNSAFE ACTS

Environmen Condition Personal

of Individual
tal Factor
Factors

Physical Technical Cognitiv Psycho Adverse

Physiologi
Environmen Environmen e Behaviou cal
t t Factors ral State Coordinati
on/
Precondition Physical Planning
s
/ Failure
for
Unsafe Acts Adverse Physiological State Mental Self
Unsaf Effect of G force Limitati Imposed
e Prescribed Drugs Perceptu
Acts Operational injury/ illness on Stress
Sudden Incapacitation al
Pre existing Physical illness/ injury Factors
Physical fatigue
Fatigue physiological/ mental
Circadian Rhythm Desynchronise
Motion Sickness, Trapped gas disorder
Evolved gas disorder
Hypoxia, Hyperventilation, Dehydration
Visual adaptation, Oversaturation
 PRECONDITION
S
FOR
UNSAFE ACTS

Environmen Condition Personal

of Individual
tal Factor
Factors

Physical Cognitiv Adverse Physical/

Environmen e Physiologi Mental
Factors cal Limitati Coordinati
t
State on on/
Technical Psycho
Precondition Planning
Environmen Behaviou
s
Perceptu Failure
for
t ral
Unsafe Acts al Self
Unsaf Factors Imposed
e
Acts Stress
Physical/Mental
Limitation
Learning ability
Memory ability
Anthropometric/ Biomechanical
Motor skill/ Coordination
Technical/ Procedural knowledge
 PRECONDITION
S
FOR
UNSAFE ACTS

Environmen Condition Personal

of Individual
tal Factor
Factors

Coordinati Self
Physical Cognitiv Adverse
on/ Imposed
Environmen e Physiologi
cal
Planning Stress
t Factors
State Failure
Technical Psycho Physical Perceptua
Precondition
s Environmen Behaviou /
l
for ral Factors
Unsafe Acts t Mental
Unsaf Limitati
e on
Acts Perceptual Factors
Illusion kinaesthetic, Vestibular, Visual
Misperception of ops conditions
Misinterpreted/ Misread instrument
Expectancy
Auditory cues
Spatial Disorientation (Type1,2 & 3)
Temporal Distortion
 PRECONDITION
S
FOR
UNSAFE ACTS

Environmen Condition Personal

of Individual Factor
tal
Factors

Coordinatio
Cognitiv Adverse Self
Physical Perceptu n/
e Physiologi Planning Imposed
Environmen al
Factors cal Failure Stress
t Factors
State
Technical Psycho Physical
Precondition
s Environmen Behaviou /
for
t ral Mental
Unsafe Acts Coordination/Planning Failure
Unsaf Limitati Crew/ Team leadership
e on Cross monitoring performance
Acts Task delegation
Rank/position authority gradient
assertiveness
Communication critical info
standard/ proper terminology
Acknowledgement/ feedback
Mission planning and briefing
Task/ Mission in progress re-planning
Miscommunication
 PRECONDITION
S
FOR
UNSAFE ACTS

Environmen Condition Personal

of Individual Factor
tal
Factors

Coordinati Self
Physical Cognitiv Adverse
Perceptu on/ Imposed
Environmen e Physiologi
al Planning Stress
Factors cal
t Factors Failure
State
Technical Psycho Physical
Precondition
s Environmen Behaviou /
for
t ral Mental
Unsafe Acts
Limitati
Self Imposed Stress
Unsaf
e on Physical fitness
Acts Alcohol
Drugs/ Supplements/
Self medication
Nutrition
Inadequate rest
Unreported Disqualifying
medical condition
 UNSAFE
SUPERVIS
ION

Inadequat Planned Failure to Supervisor

e Correct y
Inappropri
Supervisi
on ate Problem Violations
Operations

Unsafe
Supervisio
n Inadequate Supervision
Leadership/ Super vision/ Oversight
Precondition inadequate
s
for
Supervision- Modelling
Unsafe Acts Local training issue/ programs
Unsaf Supervision policy
e Supervision- Personality conflict
Acts Supervision lack of feedback
 UNSAFE
SUPERVIS
ION

Inadequa Planned Failure to Supervisor

Inappropri Correct y
te
ate
Supervisi Operations Problem Violations
on

Unsafe
Supervisio
n
Planned Inappropriate
Precondition Operations
s
for Ordered/ led on Mission beyond
Unsafe Acts
capability
Unsaf
e Crew/Team/Flight/composition
Acts Limited recent experience
Proficiency
Risk assessment formal
Authorized unnecessary hazard
 UNSAFE
SUPERVIS
ION

Inadequat Planned Failure to Supervisory

e Inappropri Correct Violations
Supervisi ate Problem
on Operations

Unsafe
Supervisio
n
Failure to Correct
Precondition
s
Problem
for
Unsafe Acts Personnel management
Unsaf Operations management
e
Acts
 UNSAFE
SUPERVIS
ION

Inadequat Planned Failure to Supervisory

e Inappropri Correct Violations
Supervisi ate Problem
on Operations

Unsafe
Supervisio
n
Supervisory Violations
Precondition
s Supervision (Discipline)
for
Unsafe Acts
Supervision Defacto policy
Direct Violation
Unsaf
e Currency
Acts
 ORGANIZATIONA
L
INFLUENCES

Resource Organizational Operational

Management Climate Process

Organization
al
Influences

Unsafe
Supervisio
n

Precondition
s
for
Unsafe Acts

Unsaf
e
Acts
 ORGANIZATIONA
L
INFLUENCES

Resource Organizationa Operational

Management l Process
Climate

Organization
al
Influences

Unsafe
Supervisio
n
RESOURCE MANAGEMENT
Precondition ATC resources
s
for Air field resources
Unsafe Acts Operator support
Unsaf Acquisition policies/ Design process
e Phase out policies
Acts Selection policies
Personnel resources
Informational resources/ support
Financial resources/ support
 ORGANIZATIONA
L
INFLUENCES

Resource Organizationa Operational

Management l Process
Climate

Organization
al
Influences

Unsafe
Supervisio
ORGANIZATIONAL
n CLIMATE
Precondition Unit/organizational values
s Evaluation/ promotion/
for
Unsafe Acts upgrade
Perception of equipment
Unsaf
e
Unit mission/ deactivation
Acts Organisational structure
 ORGANIZATIONA
L
INFLUENCES

Resource Organizationa Operational

Management l Process
Climate

Organization
al
Influences

Unsafe
Supervisio
n
OPERATIONAL
Precondition PROCESS
s Ops/ Tempo workload
for
Unsafe Acts Program & policy risk
assessment
Unsaf Procedural Guidance/
e
Acts publications
Organizational training
issues
Doctrine
Program oversight
 SUMMARY

A SYSTEM TO RECORD AND CORRELATE CAUSES OF

HUMAN FAILURE FOR FUTURE PREVENTION CONTROLS.
OVER TIME WILL PROVIDES INFORMATION THAT
CAN BE USED FOR ACCIDENT PREVENTION !
HFACS PROVIDES:
STRUCTURED
HELPS IN FRAMING QUESTION
STANDARDIZED
 PUTTING IT ALL
TOGETHER
Special Observation

Present and Contributing

Unsafe Inputs to the

Organization & an Unsafe
Operating Environment
Organizational
Factors

Unsafe
Supervision

Present but not Preconditions

for Unsafe
Contributing Acts
Unsafe Acts
 MISSION SUCCESS
Safe Inputs to the Organization &
a Safe Operating Environment

Safe
Organizational
Factors
Safe
Supervision

Preconditions
Plug the holes for Safe
& prevent the Acts
accidents! Safe Acts
 CONCLUSIO
N
IT IS OUR BELIEF THAT THE HUMANS
FACTORS ANALYSIS AND CLASSIFICATION
SYSTEM (HFACS) FRAMEWORK BRIDGES THE
GAP BETWEEN THEORY AND PRACTICE BY
PROVIDING INVESTIGATORS WITH A
COMPREHENSIVE, USER FRIENDLY TOOL FOR
IDENTIFYING AND CLASSIFYING THE HUMAN
CAUSES OR AVIATION ACCIDENTS.
SHAPPELL AND WIEGMANN – FEBRUARY 2000
QUESTIONS ?