Marine Corps Safety Managers Conference

1
Human Factors Analysis and Classification System
(HFACS)

• Marine Corps Safety Managers Conference
• 24 July 2008

2
Agenda

• Background
• Aviation HFACS
• PMV HFACS
• Progress
• Way ahead

3
AVIATION'S DILEMMA
4
WHY HFACS
2004
5
What is HFACS?

• Tool used to identify specific human causes of
  mishaps.
• Identifies contributing conditions that allowed
  mishap to occur.
• Identifies contributing factors at supervisory
  levels.
• Attempts to identify all root causes

6
Reasons Model of Human Error
"Swiss Cheese"
Unsafe Supervision
Preconditions for Unsafe Acts
Unsafe Acts
Failed or Absent Defenses
Accident Injury
Adapted from Reason 1990
Adapted from Reason (1990)
7
HFACS TAXONOMY
Organizational Climate
Organizational Process
Resource/Acquisition Management
SUPERVISION
Planned Inappropriate Operations
Failed to Correct Known Problem
Inadequate Supervision
Supervisory Violations
PRECONDITIONS
Personnel Factors
Environmental Factors
Coordination/ Communication/ Planning Factors
Technological Environment
Physical Environment
Self-Imposed Stress
Condition of Individuals
Adverse Physiological States
Cognitive Factors
Psycho-Behavioral
Perceptual Factors
Physical/ Mental Limitations
ACTS
Errors
Violations
Perception Errors
Skill-Based Errors
Judgment and Decision-Making Errors
8
HFACS PMV Plan of Action

• Safety managers meeting (Jan 08)
• Coordination (Clemson/NAVSAFECEN)
• Data Gathering (Apr 08)
• Data Analysis
• Initial Results (Jun 08)
• SOW developed
• Issue paper submitted (Jun 08)
• Detailed Data analysis (Aug 08)
• Final products (Sep 09)

9
Initial Results

• Y99-07 Class A B mishaps analyzed
• 617 Total mishaps
• 338 Assigned causal codes
• 279 Insufficient data/non-PMV events
• Results
• Skill-based error (50-75 percent)
• Violations (25-33 percent)
• Unsafe act causal factors (flat or increasing)

10
Way Ahead

• SOW
• Cost 13,500.00 to 17,750.00
• Deliverables
• Fully developed taxonomy
• Field guide
• WESS modifications
• Intervention strategies
• Program/policy enhancements
• 30 Sep 09
• Study concludes

11
HFAC PMV
Questions ?