HFACS Presentation

1
HUMAN FACTORS ANALYSIS AND CLASSIFICATION
SYSTEM (HFACS)
THE FIRST STEP IN THE RISK MANAGEMENT PROCESS
2
Human beings by their very nature make mistakes
therefore, it is unreasonable to expect
error-free human performance. Shappell
Wiegmann, 1997
3
NAVAL AVIATION MISHAP RATE
FY 50-96
Angled Carrier Decks Naval Aviation Safety
Center NAMP est. 1959 RAG concept
initiated NATOPS initiated 1961 Squadron
Safety program System Safety
Designated Aircraft ACT HFC
s
60
50
40
30
Class A Mishaps/100,000 Flight Hours
20
2.39
10
0
50
65
80
96
Fiscal Year
4
All NAVY/MARINE Class A, B, C Mishaps
16
14
12
Human
10
8
Class A, B, C Mishaps/100,000 Flight Hours
6
4
Mechanical
2
0
1979
1981
1987
1977
1983
1985
1989
1991
Year
Shappell Wiegmann, 1996
5
Active versus Latent Failures (Reason, 1990)

• Active Conditions
• Failed to Scan Instruments
• Penetrated IMC when VMC only

Failed or Absent Defenses
6
Active versus Latent Failures (Reason, 1990)

• Latent Conditions
• Poor CRM
• Mental Fatigue

Preconditions for Unsafe Acts
Unsafe Acts

• Active Conditions
• Failed to Scan Instruments
• Penetrated IMC when VMC only

Failed or Absent Defenses
7
Active versus Latent Failures (Reason, 1990)

• Latent Conditions
• Deficient training program
• Improper crew pairing

Unsafe Supervision

• Latent Conditions
• Poor CRM
• Mental Fatigue

Preconditions for Unsafe Acts
Unsafe Acts

• Active Conditions
• Failed to Scan Instruments
• Penetrated IMC when VMC only

Failed or Absent Defenses
8
Active versus Latent Failures (Reason, 1990)

• Latent Conditions
• Excessive cost cutting
• Inadequate promotion policies

• Latent Conditions
• Deficient training program
• Improper crew pairing

Unsafe Supervision

• Latent Conditions
• Poor CRM
• Mental Fatigue

Preconditions for Unsafe Acts
Unsafe Acts

• Active Conditions
• Failed to Scan Instruments
• Penetrated IMC when VMC only

Failed or Absent Defenses

• Accident Injury
• Crashed into side of
• mountain

9
UNSAFE ACTS
10
UNSAFE ACTS
Errors
Violations
Perceptual Errors
Skill-Based Errors
Exceptional
Routine

• Rule-based Decisions
• - If X, then do Y
• - Highly Procedural
• Choice Decisions
• - Knowledge-based
• Ill-Structured Decisions
• - Problem solving

11
UNSAFE ACTS
Errors
Violations
Perceptual Errors
Exceptional
Routine

• Attention Failures
• - Breakdown in visual scan
• - Inadvertent operation of control
• - Failure to see and avoid
• Memory Failure
• - Omitted item in checklist
• - Omitted step in procedure

12
UNSAFE ACTS
Errors
Violations
Perceptual Errors
Exceptional
Routine

• Misjudge Distance,
• Altitude, Airspeed
• Spatial Disorientation
• Visual Illusions

13
Errors
Perceptual Errors
Exceptional

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

14
Errors
Perceptual Errors
Routine
Exceptional

• Violated NATOPS/Regulations/SOP
• - Performed Unauthorized Acrobatic Maneuver
• - Canyon Running
• - Failed to Complete Performance Computations
  for Flight
• - Improper Takeoff Technique
• - Failed to Obtain Valid Weather Brief
• Accepted Unnecessary Hazard
• Not Current/Qualified for Mission
• Exceeded Limits of Aircraft

15
(No Transcript)
16
PRECONDITIONS FOR UNSAFE ACTS
Substandard Conditions of Operators
Substandard Practices of Operators
Adverse Physiological States
Physical/ Mental Limitations
Adverse Mental States
Personal Readiness
Crew Resource Mismanagement

• Loss of Situational Awareness
• Circadian dysrhythmia
• Alertness (Drowsiness)
• Overconfidence
• Complacency
• Task Fixation

17

• G-induced Loss of Consciousness
• Hypoxia
• Motion Sickness
• Medical Illness
• Intoxication

18
Physical/ Mental Limitations

• Lack of Sensory Input
• Limited Reaction Time
• Incompatible Physical Capabilities
• Incompatible Intelligence/Aptitude

19

• Not Working as a Team
• Poor Aircrew Coordination
• Improper Briefing Before a Mission
• Inadequate Coordination of Flight

20

• Readiness Violations
• Crew Rest Requirements
• Bottle-to-Brief Rules
• Self-Medicating
• Poor Judgement
• Poor Dietary Practices
• Overexertion While Off Duty
• Excessive Voluntary PT

21
UNSAFE SUPERVISION
22
Planned Inappropriate Operations
Failed to Correct Problem
Inadequate Supervision
Supervisory Violations

• Failure to Administer Proper Training
• Lack of Professional Guidance

23
UNSAFE SUPERVISION
Planned Inappropriate Operations
Failed to Correct Problem
Inadequate Supervision
Supervisory Violations

• Mission Risk without Benefit
• Improper Work Tempo
• Poor Crew Pairing

24
UNSAFE SUPERVISION
Planned Inappropriate Operations
Failed to Correct Problem
Inadequate Supervision
Supervisory Violations

• Failure to Correct Inappropriate Behavior
• Failure to Correct a Safety Hazard

25
UNSAFE SUPERVISION
Planned Inappropriate Operations
Failed to Correct Problem
Inadequate Supervision

• Not Adhering to Rules and Regulations
• Willful Disregard for Authority by
• Supervisors

26
(No Transcript)
27

• Human
• Monetary
• Equipment/Facility

28

• Structure
• Policies
• Culture

29

• Operations
• Procedures
• Oversight

30
(No Transcript)
31
Whenever we talk about a pilot who has been
killed in a flying accident, we should all keep
one thing in mind. He...made a judgment. He
believed in it so strongly that he knowingly bet
his life on it. That his judgment was faulty is
a tragedy,
Every instructor, supervisor, and contemporary
who ever spoke to him had the opportunity to
influence his judgement, so a little bit of all
of us goes with every pilot we lose.
--Anonymous