Human Factors and Classification System

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					 The DoD Human Factors Analysis
and Classification System (HFACS)
“Human beings by their very nature make mistakes; therefore,
 it is unreasonable to expect error-free human performance.”
                     Shappell & Wiegmann, 1997



   It is not surprising then, that
 human error has been implicated
    in 60-90% of all accidents.



  However, the rate of human error
  accidents has remained relatively
    stable over the past 20 years,
  whereas accidents associated with
   mechanical failures have been
        virtually eliminated.
        Mishaps
The cost of doing business?



Purpose of Mishap Analysis?
           (Remember the 3 W’s)
  1. What Happen ?
  2. Why it Happened ?
  3. What to do to prevent it ?
        HFACS: Background
 Developed at the Navy Safety Center in the late
  1980’s
 Based on various theories of human error
 Originally intended for aviation operations
 2006 version refined for use in any operational and
  off-duty event
 Used as a retrospective analysis tool – a reanalysis of
  MAB facts/findings with this tool
 Did not go into the MAR
            HFACS: Benefits
 Structured analysis of human error
   – Sophisticated, complete…yet operational
   – Detects error patterns current methods miss
 Get to the “why”… not just the “what”
   – More insightful root cause determination
   – Better CO decisions… more effective ORM
 A new, data-driven approach
   – Supports research across the Force
   – Easily applied to large body of existing data
   – Easily applied to new incidents and mishaps
 Can be used for more than Operational purposes
   – Can be a tool for Risk Management
   – Applies to both on-duty and off-duty evolutions
                               HFACS: Tiers
                      Organizational

                                                            Latent Failures/Conditions
                                  Supervision



                                           Preconditions



                                                           Acts             Active Failures


              Deficient or Immature
                    Conditions
                                                                         Accident & Injury




Adapted from Reason (1990)
                                                ORGANIZATIONAL
                                                  INFLUENCES


                       Resource/Acquisition        Organizational         Organizational
                           Management                 Climate                Process



                                                    SUPERVISION



                                            Planned                Failed to
              Inadequate                                                               Supervisory
                                         Inappropriate          Correct Known
              Supervision                                                               Violations
                                          Operations               Problem


                                                 PRECONDITIONS



       Environmental                                                                                 Personnel
          Factors                                                                                     Factors


  Physical     Technological                                                        Coordination/                  Self-
                                                    Condition of                   Communication/                Imposed
Environment    Environment                          Individuals                    Planning Factors               Stress


                                   Psycho-             Adverse            Physical/           Perceptual
               Cognitive
                                  Behavioral         Physiological         Mental              Factors
                Factors
                                   Factors              States           Limitations


                                                         ACTS



                             Errors                                              Violations


   Judgment and            Skill-Based           Perception
  Decision-Making            Errors               Errors
       Errors
                                          ACTS




                             Errors                        Violations



    Judgment and Decision   Skill-Based    Misperception
          Errors              Errors          Errors




Unsafe
 Acts
                                             ACTS




                             Errors                                 Violations



    Judgment and Decision   Skill-Based        Misperception
          Errors              Errors              Errors




                                      DECISION ERRORS
                              Risk Assessment – During Operation
Unsafe                        Task Misprioritization
 Acts                         Necessary Action – Rushed
                              Necessary Action – Delayed
                              Caution/Warning – Ignored
                              Decision-Making During Operation
                                            ACTS




                             Errors                              Violations



    Judgment and Decision   Skill-Based      Misperception
          Errors              Errors            Errors




                                             SKILL-BASED ERRORS
                                          Inadvertent Operation
Unsafe                                    Checklist Error
 Acts
                                          Procedural Error
                                          Overcontrol/Undercontrol
                                          Breakdown in Visual Scan
                                          Inadequate Anti-G Straining Maneuver
                                               ACTS




                             Errors                                   Violations



    Judgment and Decision   Skill-Based          Misperception
          Errors              Errors                Errors




                                   MISPERCEPTION ERRORS
Unsafe                                    (due to)
 Acts                             Misjudge Distance, Altitude, Airspeed
                                  Spatial Disorientation
                                  Visual Illusions
                                                ACTS




                             Errors                                      Violations



    Judgment and Decision   Skill-Based            Misperception
          Errors              Errors               VIOLATIONS
                                                      Errors
                                     (Willful disregard for rules and instructions!)
                                    Violation – Based on Risk Assessment
                                    Violation – Routine/Widespread
                                    Violation – Lack of Discipline




Unsafe
 Acts
                                                       PRECONDITIONS




                 Environmental                                                                  Personnel
                    Factors                                                                      Factors



         Physical         Technological                                             Coordination/             Self-
       Environment        Environment                    Condition of
                                                                                   Communication/           Imposed
                                                         Individuals
                                                                                   Planning Factors          Stress



                         Cognitive         Psycho-         Adverse        Physical/        Perceptual
                          Factors         Behavioral     Physiological     Mental           Factors
Preconditions                              Factors          States       Limitations
     for
 Unsafe Acts

                Unsafe
                 Acts
                                                        PRECONDITIONS




                 Environmental                                                                      Personnel
                    Factors                                                                          Factors



         Physical         Technological                                                 Coordination/             Self-
       Environment        Environment                      Condition of
                                                                                       Communication/           Imposed
                                                           Individuals
                                                                                       Planning Factors          Stress



                         Cognitive         Psycho-           Adverse        Physical/          Perceptual
                          Factors         Behavioral       Physiological     Mental             Factors
Preconditions                              Factors            States       Limitations
     for
 Unsafe Acts                                           PHYSICAL ENVIRONMENT
                                                       Icing/Fog/Etc. on windows
                Unsafe                                 Meteorological Conditions
                 Acts
                                                       Dust/Smoke/Etc. in Workspace
                                                       Brownout/Whiteout
                                                       Thermal Stress: Cold/Hot
                                                       Maneuvering Forces In-Flight
                                                       Noise Interference
                                                       PRECONDITIONS




                 Environmental                                                                   Personnel
                    Factors                                                                       Factors



         Physical         Technological                                              Coordination/             Self-
       Environment        Environment                     Condition of
                                                                                    Communication/           Imposed
                                                          Individuals
                                                                                    Planning Factors          Stress



                         Cognitive         Psycho-          Adverse        Physical/        Perceptual
                          Factors         Behavioral      Physiological     Mental           Factors
Preconditions                              Factors           States       Limitations
     for
 Unsafe Acts                                                TECHNOLOGICAL
                Unsafe
                                                             ENVIRONMENT
                 Acts                                  Seating and Restraints
                                                       Instrument and Sensory Feedback
                                                       Visibility Restrictions
                                                       Controls and Switches
                                                       Automation
                                                       Personal Equipment Interference
                                                       Communications - Equipment
                                                         PRECONDITIONS




                 Environmental                                                                       Personnel
                    Factors                                                                           Factors



         Physical         Technological                                                  Coordination/             Self-
       Environment        Environment                      Condition of
                                                                                        Communication/           Imposed
                                                           Individuals
                                                                                        Planning Factors          Stress



                         Cognitive           Psycho-         Adverse           Physical/        Perceptual
                          Factors           Behavioral     Physiological        Mental           Factors
Preconditions                                Factors          States          Limitations
     for
 Unsafe Acts
                                             COORD/COMM/PLAN
                Unsafe                    Crew/Team Leadership
                 Acts                     Cross-Monitoring Performance
                                          Task Delegation
                                          Rank/Position Authority Gradient
                                          Communicating Critical Info
                                          Standard/Proper Terminology
                                          Mission Briefing
                                          Miscommunication
                                                       PRECONDITIONS




                 Environmental                                                                  Personnel
                    Factors                                                                      Factors



         Physical         Technological                                             Coordination/             Self-
       Environment        Environment                    Condition of
                                                                                   Communication/           Imposed
                                                         Individuals
                                                                                   Planning Factors          Stress



                         Cognitive         Psycho-         Adverse        Physical/        Perceptual
                          Factors         Behavioral     Physiological     Mental           Factors
Preconditions                              Factors          States       Limitations
     for
 Unsafe Acts
                                                   SELF-IMPOSED STRESS
                Unsafe                          Physical Fitness
                 Acts                           Alcohol
                                                Drugs/Supplements/Self Medication
                                                Nutrition
                                                Inadequate Rest
                                                Unreported Disqualifying Medical
                                                Condition
                                                       PRECONDITIONS




                 Environmental                                                                   Personnel
                    Factors                                                                       Factors



         Physical         Technological                                              Coordination/             Self-
       Environment        Environment                    Condition of
                                                                                    Communication/           Imposed
                                                         Individuals
                                                                                    Planning Factors          Stress



                         Cognitive         Psycho-         Adverse        Physical/         Perceptual
                          Factors         Behavioral     Physiological     Mental            Factors
Preconditions                              Factors          States       Limitations
     for
 Unsafe Acts

                Unsafe                             COGNITIVE FACTORS
                 Acts                           Inattention
                                                Channelized Attention
                                                Cognitive Task Oversaturation
                                                Confusion
                                                Negative Transfer
                                                Distraction
                                                Geographic Misorientation (Lost)
                                                Checklist Interference
                                                       PRECONDITIONS




                 Environmental                                                                   Personnel
                    Factors                                                                       Factors



         Physical         Technological                                              Coordination/             Self-
       Environment        Environment                    Condition of
                                                                                    Communication/           Imposed
                                                         Individuals
                                                                                    Planning Factors          Stress



                         Cognitive         Psycho-         Adverse         Physical/        Perceptual
                          Factors         Behavioral     Physiological      Mental           Factors
Preconditions                              Factors          States        Limitations
     for
 Unsafe Acts

                Unsafe
                                                   PSYCHO-BEHAVIORAL
                 Acts                            Pre-Existing Personality Disorder
                                                 Pre-Existing Psychological Disorder
                                                 Emotional State
                                                 Personality Style
                                                 Overconfidence
                                                 Complacency
                                                 Get-Home-Itis/Get-There-Itis
                                                 Overaggressive
                                                       PRECONDITIONS




                 Environmental                                                                    Personnel
                    Factors                                                                        Factors



         Physical         Technological                                               Coordination/             Self-
       Environment        Environment                    Condition of
                                                                                     Communication/           Imposed
                                                         Individuals
                                                                                     Planning Factors          Stress



                         Cognitive         Psycho-         Adverse          Physical/        Perceptual
                          Factors         Behavioral     Physiological       Mental           Factors
Preconditions                              Factors          States         Limitations
     for
 Unsafe Acts

                Unsafe                                            ADVERSE PHYSIOLOGICAL
                 Acts
                                                                  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
                                                       PRECONDITIONS




                 Environmental                                                                  Personnel
                    Factors                                                                      Factors



         Physical         Technological                                             Coordination/             Self-
       Environment        Environment                    Condition of
                                                                                   Communication/           Imposed
                                                         Individuals
                                                                                   Planning Factors          Stress



                         Cognitive         Psycho-         Adverse        Physical/        Perceptual
                          Factors         Behavioral     Physiological     Mental           Factors
Preconditions                              Factors          States       Limitations
     for
 Unsafe Acts

                Unsafe                    PHYSICAL/MENTAL LIMITS
                 Acts
                                          Learning Ability/Rate
                                          Memory Ability/Lapses
                                          Anthropometric/Biomechanical Limits
                                          Motor Skill/Coordination or Timing
                                          Deficiency
                                          Technical/Procedural Knowledge
                                                       PRECONDITIONS




                 Environmental                                                                   Personnel
                    Factors                                                                       Factors



         Physical         Technological                                              Coordination/             Self-
       Environment        Environment                    Condition of
                                                                                    Communication/           Imposed
                                                         Individuals
                                                                                    Planning Factors          Stress



                         Cognitive         Psycho-         Adverse         Physical/        Perceptual
                          Factors         Behavioral     Physiological      Mental           Factors
Preconditions                              Factors          States        Limitations
     for
 Unsafe Acts

                Unsafe                                       PERCEPTUAL FACTORS
                 Acts
                                                          Illusions: Kinesthetic/Vestibular/Visual
                                                          Misperception of Operational Conditions
                                                          Misinterpreted/Misread Instrument
                                                          Expectancy
                                                          Auditory Cues
                                                          Spatial Disorientation: 1, 2, & 3
                                                          Temporal Distortion
                                                SUPERVISION



                                          Planned         Failed to
                       Inadequate                                      Supervisory
                                       Inappropriate   Correct Known
                       Supervision                                      Violations
                                        Operations        Problem




  Unsafe
Supervision


              Preconditions
                   for
               Unsafe Acts

                              Unsafe
                               Acts
                                                 SUPERVISION



                                          Planned             Failed to
                       Inadequate                                              Supervisory
                                       Inappropriate       Correct Known
                       Supervision                                              Violations
                                        Operations            Problem




  Unsafe
Supervision
                                          INADEQUATE SUPERVISION
                                       Leadership/Supervision/Oversight Inadequate
              Preconditions            Supervision – Modeling
                   for                 Local Training Issues/Programs
               Unsafe Acts             Supervision – Policy
                                       Supervision – Personality Conflict
                              Unsafe
                               Acts    Supervision – Lack of Feedback
                                                SUPERVISION



                                          Planned           Failed to
                       Inadequate                                            Supervisory
                                       Inappropriate     Correct Known
                       Supervision                                            Violations
                                        Operations          Problem




  Unsafe
Supervision                                  PLANNED INAPPROPRIATE
                                                  OPERATIONS
              Preconditions                 Ordered/Led Mission Beyond Capability
                   for                      Crew/Team/Flight Makeup/Composition
               Unsafe Acts                  Limited Recent Experience
                                            Limited Total Experience
                              Unsafe        Proficiency
                               Acts
                                            Risk Assessment – Formal
                                            Authorized Unnecessary Hazard
                                                SUPERVISION



                                          Planned          Failed to
                       Inadequate                                       Supervisory
                                       Inappropriate    Correct Known
                       Supervision                                       Violations
                                        Operations         Problem




  Unsafe
Supervision                                     FAILED TO CORRECT A
                                                  KNOWN PROBLEM
              Preconditions              Personnel Management
                   for                   Operations Management
               Unsafe Acts

                              Unsafe
                               Acts
                                                SUPERVISION



                                          Planned            Failed to
                       Inadequate                                               Supervisory
                                       Inappropriate      Correct Known
                       Supervision                                               Violations
                                        Operations           Problem




  Unsafe
Supervision
                                                  SUPERVISORY VIOLATIONS
              Preconditions                     Supervision – Discipline Enforcement
                   for                          Supervision – De Facto Policy
               Unsafe Acts                      Directed Violation
                                                Currency
                              Unsafe
                               Acts
                                                 ORGANIZATIONAL
                                                   INFLUENCES


                 Resource/Acquisition              Organizational   Organizational
                    Management                        Climate          Process




Organizational
  Influences


               Unsafe
             Supervision



                        Preconditions
                             for
                         Unsafe Acts


                                        Unsafe
                                         Acts
                                                       ORGANIZATIONAL
                                                         INFLUENCES


                 Resource/Acquisition                      Organizational                 Organizational
                    Management                                Climate                        Process




Organizational
  Influences                                     RESOURCE/ACQUISITION
                                                     MANAGEMENT
               Unsafe
             Supervision
                                                 Air Traffic Control Resources
                                                 Airfield Resources
                                                 Operator Support
                        Preconditions            Acquisition Policies/Design Processes
                             for
                         Unsafe Acts             Attrition Policies
                                                 Accession/Selection Policies
                                        Unsafe   Personnel Resources
                                         Acts    Information Resources/Support
                                                 Financial Resources/Support
                                                  ORGANIZATIONAL
                                                    INFLUENCES


                 Resource/Acquisition                 Organizational                   Organizational
                    Management                           Climate                          Process




Organizational                                       ORGANIZATIONAL
  Influences
                                                        CLIMATE
               Unsafe                            Unit/Organizational Values/Culture
             Supervision                         Evaluation/Promotion/Upgrade
                                                 Perceptions of Equipment
                        Preconditions            Unit Mission/Aircraft Change
                             for                 Unit Deactivation
                         Unsafe Acts
                                                 Organizational Structure
                                        Unsafe
                                         Acts
                                                 ORGANIZATIONAL
                                                   INFLUENCES


                 Resource/Acquisition               Organizational                   Operational
                                                                                    Organizational
                    Management                         Climate                         Process




Organizational
  Influences                                             ORGANIZATIONAL
                                                            PROCESS
               Unsafe
             Supervision                         Ops Tempo/Workload
                                                 Program and Policy Risk Assessment
                                                 Procedural Guidance/Publications
                        Preconditions
                             for                 Organizational Training Issues/Programs
                         Unsafe Acts             Doctrine
                                                 Program Oversight/Program Management
                                        Unsafe
                                         Acts
                                                ORGANIZATIONAL
                                                  INFLUENCES


                       Resource/Acquisition        Organizational         Organizational
                           Management                 Climate                Process



                                                    SUPERVISION



                                            Planned                Failed to
              Inadequate                                                               Supervisory
                                         Inappropriate          Correct Known
              Supervision                                                               Violations
                                          Operations               Problem


                                                 PRECONDITIONS



       Environmental                                                                                 Personnel
          Factors                                                                                     Factors


  Physical     Technological                                                        Coordination/                  Self-
                                                    Condition of                   Communication/                Imposed
Environment    Environment                          Individuals                    Planning Factors               Stress


                                   Psycho-             Adverse            Physical/           Perceptual
               Cognitive
                                  Behavioral         Physiological         Mental              Factors
                Factors
                                   Factors              States           Limitations


                                                         ACTS



                             Errors                                              Violations


   Judgment and            Skill-Based           Perception
  Decision-Making            Errors               Errors
       Errors
Night Watch - 150
Night Watch - 150
                    HFACS: Approach
   Integrate HFACS into the mishap investigation process
    – All MAB members participate in the HFACS analysis (NOT JUST
      SAFETY and MEDICAL OFFICER)
        read DoD HFACS Guide to know the process and factors
          (nanacodes)
        conduct preliminary HFACS analysis on mishap message info


    – Use HFACS to plan and conduct the „fact finding‟ and interview process
           Seek evidence to accept or reject „nanacodes‟
           Document facts/evidence that justifies selecting the „nanocode‟

    – Identify which nanocodes are “causal” and which are “contributing”
           Causal – direct link to the mishap or respond “NO” to the question, would
            the mishap have occurred if the nanocode was removed?
           Contributory – no direct link to the mishap and respond “YES” to the
            question, would the mishap have occurred if the nanocode was removed?
           Conduct a flow analysis to identify the interaction and influence of all the
            nanacodes to the mishap
           HFACS: Documentation
   PC307 Fatigue (Physiological/Mental):
    – Both the qualified coxswain and the break-in coxswain stated they were
      well rested and alert. However, numerous boat crew members
      expressed being tired and getting little sleep (3-4 hours) during the
      previous days. Watch logs confirmed that some of the boat crew stood
      watch that night or morning. Unfortunately, 72-hour histories were not
      provided to conduct endurance assessments, but the vast majority of
      crew interviewed claimed to have 3-5 hours of sleep the night prior.

    – The CO gave order “slow and steady”, a typical behavioral
      countermeasure for when an individual is compromised due to fatigue.
      Individuals realize their physical and cognitive states may be “dulled”
      due to fatigue, and thus slow down and verify everything they do.
                                HFACS: Analysis
                                                                              Limited Recent
                                              Workspace Incompatible         Experience (SP003)
                           Get There It Is     with Human (PE206)
                             (PC213)
 Negative Transfer
    (PC105)
                                                                  Local Training Issue
                                                                        (SI003)
 Complacency
   (PC208)                           Overcontrol/
                                     Undercontrol
  Distraction                         (AE104)
   (PC106)                                                  Risk Assessment –
                                                            During Ops (AE204)
  Inattention           Breakdown of
    (PC101)          visual scan (AE105)

                                              Capsize
                                                                              Necessary Action
         Fatigue                                                              Delayed (AE204)
        (PC307)

                                                                                          Cross-Monitoring
                         Ops Tempo/Workload
                                                                                         Performance(PP102)
                               (OP001)                          Unit/Org Values/
                                                                Culture (OC001)
Risk Assessment –
                                                                              Red HFACS = Causal
 Formal (SP006)
                                                                                                   40
                                                                              Black HFACS = Contributory
           HFACS: Status
 Training - flight surgeons and safety
  personnel
 Update HFACS User Guide
 E-Mishap system updated
 Expand use of HFACS beyond Class A/B
  mishaps
 Risk management tool
Case Scenario I




    Street_luge_240x160.mpg
                                                ORGANIZATIONAL
                                                  INFLUENCES


                       Resource/Acquisition        Organizational         Organizational
                           Management                 Climate                Process



                                                    SUPERVISION



                                            Planned                Failed to
              Inadequate                                                               Supervisory
                                         Inappropriate          Correct Known
              Supervision                                                               Violations
                                          Operations               Problem


                                                 PRECONDITIONS



       Environmental                                                                                 Personnel
          Factors                                                                                     Factors


  Physical     Technological                                                        Coordination/                  Self-
                                                    Condition of                   Communication/                Imposed
Environment    Environment                          Individuals                    Planning Factors               Stress


                                   Psycho-             Adverse            Physical/           Perceptual
               Cognitive
                                  Behavioral         Physiological         Mental              Factors
                Factors
                                   Factors              States           Limitations


                                                         ACTS



                             Errors                                              Violations


   Judgment and            Skill-Based           Perception
  Decision-Making            Errors               Errors
       Errors
                     HFACS
   Acts
    – Breakdown visual scan
    – Risk Assessment


   Preconditions
    – Distraction
    – Communicating Critical Information*
    – Mission Planning
                        HFACS
   Supervision
    – Failure to correct known problem
          Operations mgmt


   Organization
    – Airfield Resources (Unsafe Track Condition)
         Poor                Poor
    Risk Assessment    Mission Planning


                                           Failure to Correct
                                            Known Problem

Distraction



                                                                Unsafe Track
                      Pole Strike                                Condition
Brkdwn vis scan




                               Commm Critical
                                 Information
         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@uscg.mil
http://www.uscg.mil/safety