USAIR

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A FAILURE ANALYSIS AND CLASSIFICATION SYSTEM
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UNSAFE ACTS
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UNSAFE ACTS
Errors
Violations
Perceptual Errors
Skill-Based Errors
Exceptional
Routine

• Rule-based
• - Misapplication of a good rule
• - Application of a bad rule
• Knowledge-based
• - Inaccurate or incomplete
• knowledge of the problem

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UNSAFE ACTS
Errors
Violations
Perceptual Errors
Exceptional
Routine

• Attention Failures
• Memory Failure

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UNSAFE ACTS
Errors
Violations
Perceptual Errors
Exceptional
Routine

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

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Errors
Perceptual Errors
Exceptional

• Habitual departures from rules condoned by
  management

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Errors
Perceptual Errors
Routine
Exceptional

• Isolated departures from rules
• NOT condoned by management

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PRECONDITIONS FOR UNSAFE ACTS
Substandard Conditions of Operators
Substandard Practices of Operators
Adverse Physiological States
Physical/ Mental Limitations
Adverse Mental States
Interpersonal Resource Mismanagement
Personal Readiness

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

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• Hypoxia
• Motion Sickness
• Medical Illness
• Intoxication

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Physical/ Mental Limitations

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

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

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

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UNSAFE SUPERVISION
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• Failure to Administer Proper Training
• Lack of Professional Guidance

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• Improper Work Tempo
• Poor Crew Pairing

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

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

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• Human
• Monetary
• Equipment/Facility

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• Structure
• Policies
• Culture

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• Operations
• Procedures
• Oversight