jssc, 1998 hfacs - the first step in the risk management process human factors analysis and...
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JSSC, 1998 HFACS - The first step in the risk management process
HUMAN FACTORS ANALYSIS AND HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEMCLASSIFICATION SYSTEM
(HFACS)(HFACS)
THE FIRST STEP IN THE THE FIRST STEP IN THE RISK MANAGEMENT RISK MANAGEMENT
PROCESSPROCESS
JSSC, 1998 HFACS - The first step in the risk management process
““Human beings by their very nature make Human beings by their very nature make mistakes; therefore, it is unreasonable to mistakes; therefore, it is unreasonable to expect error-free human performance.” expect error-free human performance.” Shappell & Wiegmann,Shappell & Wiegmann, 1997 1997
JSSC, 1998 HFACS - The first step in the risk management process
NAVAL AVIATION MISHAP RATENAVAL AVIATION MISHAP RATE
776 aircraftdestroyed in
1954
FY 50-96FY 50-96
Fiscal Year
2.39
39 aircraftdestroyed in
1996
0
10
20
30
40
50
60
50 65 80 96
Angled Carrier DecksNaval Aviation Safety Center
NAMP est. 1959RAG concept initiated
NATOPS initiated 1961Squadron Safety program
System Safety Designated Aircraft
ACTHFC’s
Cla
ss A
Mis
hap
s/1
00
,00
0 F
lig
ht
Hou
rs
JSSC, 1998 HFACS - The first step in the risk management process
All NAVY/MARINE Class A, B, & C MishapsAll NAVY/MARINE Class A, B, & C Mishaps
Shappell & Wiegmann, 1996
Cla
ss A
, B
,& C
Mis
hap
s/1
00
,00
0 F
lig
ht
Hou
rs
0
2
4
6
8
10
12
14
16
19
77
19
79
19
81
19
83
19
85
19
87
19
89
19
91
Year
Mechanical
Human
JSSC, 1998 HFACS - The first step in the risk management process
Active ConditionsFailed to Scan Instruments
Penetrated IMC when VMC only
UnsafeActs
Active versus Latent Failures (Reason, 1990)
Failed orAbsent Defenses
JSSC, 1998 HFACS - The first step in the risk management process
Latent ConditionsPoor CRM
Mental Fatigue
Active ConditionsFailed to Scan Instruments
Penetrated IMC when VMC onlyFailed orAbsent Defenses
Preconditionsfor
Unsafe Acts
UnsafeActs
Active versus Latent Failures (Reason, 1990)
JSSC, 1998 HFACS - The first step in the risk management process
Latent ConditionsDeficient training program
Improper crew pairing
Latent ConditionsPoor CRM
Mental Fatigue
Active ConditionsFailed to Scan Instruments
Penetrated IMC when VMC onlyFailed orAbsent Defenses
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Active versus Latent Failures (Reason, 1990)
JSSC, 1998 HFACS - The first step in the risk management process
Latent ConditionsExcessive cost cutting
Inadequate promotion policies
Latent ConditionsDeficient training program
Improper crew pairing
Latent ConditionsPoor CRM
Mental Fatigue
Active ConditionsFailed to Scan Instruments
Penetrated IMC when VMC onlyFailed orAbsent Defenses
OrganizationalFactors
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Accident & InjuryCrashed into side
of
mountain
Active versus Latent Failures (Reason, 1990)
JSSC, 1998 HFACS - The first step in the risk management process
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ViolationsErrorsErrors
ExceptionalRoutinePerceptualErrors
DecisionErrors
Skill-BasedErrors
JSSC, 1998 HFACS - The first step in the risk management process
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
DecisionErrors
DECISION ERROR Rule-based Decisions - If X, then do Y - Highly Procedural Choice Decisions - Knowledge-based Ill-Structured Decisions - Problem solving
JSSC, 1998 HFACS - The first step in the risk management process
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
Skill-BasedErrors
SKILL-BASEDERRORS
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
JSSC, 1998 HFACS - The first step in the risk management process
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
PERCEPTUALERRORS
Misjudge Distance, Altitude, Airspeed Spatial Disorientation Visual Illusions
JSSC, 1998 HFACS - The first step in the risk management process
Exceptional
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ROUTINE (INFRACTIONS)(Habitual departures from rules condoned by management)
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
JSSC, 1998 HFACS - The first step in the risk management process
Routine
Violations
Exceptional
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Unsafe
Acts
Exceptional
Violations
Exceptional
UNSAFEACTS
UNSAFEACTS
EXCEPTIONAL(Isolated departures from the rules not condoned
by management)
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
JSSC, 1998 HFACS - The first step in the risk management process
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Crew Resource Mismanagemen
t
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Preconditionsfor
Unsafe Acts
UnsafeActs
JSSC, 1998 HFACS - The first step in the risk management process
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Crew Resource Mismanagemen
t
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Adverse Mental States
ADVERSE MENTAL STATE
Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation
JSSC, 1998 HFACS - The first step in the risk management process
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Crew Resource Mismanagemen
t
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Adverse Physiologic
al States
ADVERSE PHYSIOLOGICALSTATES
G-induced Loss of Consciousness Hypoxia Motion Sickness Medical Illness Intoxication
JSSC, 1998 HFACS - The first step in the risk management process
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Crew Resource Mismanagemen
t
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Physical/Mental
Limitations
PHYSICAL/MENTALLIMITATIONS
Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude
JSSC, 1998 HFACS - The first step in the risk management process
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Interpersonal Resource
Mismanagement
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Crew Resource Mismanagemen
t
CREW RESOURCEMISMANAGEMENT
Not Working as a Team Poor Aircrew Coordination Improper Briefing Before a Mission Inadequate Coordination of Flight
JSSC, 1998 HFACS - The first step in the risk management process
Preconditionsfor
Unsafe Acts
UnsafeActs
Substandard
Conditions of
Operators
Substandard
Conditions of
Operators
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
Crew Resource Mismanagemen
t
Adverse Physiologic
al States
Physical/Mental
Limitations
Adverse Mental States
Substandard Practices
of Operators
Substandard Practices
of Operators
PRECONDITIONSFOR
UNSAFE ACTS
Personal Readines
s
PERSONAL READINESSReadiness Violations
Crew Rest Requirements Bottle-to-Brief Rules Self-Medicating
Poor Judgement Poor Dietary Practices Overexertion While Off
Duty Excessive “Voluntary”
PT
JSSC, 1998 HFACS - The first step in the risk management process
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
JSSC, 1998 HFACS - The first step in the risk management process
UNSAFESUPERVISION
UNSAFESUPERVISION
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
InadequateSupervision
INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance
JSSC, 1998 HFACS - The first step in the risk management process
UNSAFESUPERVISION
UNSAFESUPERVISION
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
PlannedInappropriate
Operations
PLANNED INAPPROPRIATEOPERATIONS
Mission Risk without Benefit Improper Work Tempo Poor Crew Pairing
JSSC, 1998 HFACS - The first step in the risk management process
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
Failed toCorrectProblem
UNSAFESUPERVISION
UNSAFESUPERVISION
FAILED TO CORRECT AKNOWN PROBLEM
Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard
JSSC, 1998 HFACS - The first step in the risk management process
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
SUPERVISORY VIOLATIONS Not Adhering to Rules and Regulations Willful Disregard for Authority by Supervisors
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
JSSC, 1998 HFACS - The first step in the risk management process
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
JSSC, 1998 HFACS - The first step in the risk management process
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
ResourceManagement
ResourceManagement
ORGANIZATIONALINFLUENCES
RESOURCE MANAGEMENT Human Monetary Equipment/Facility
JSSC, 1998 HFACS - The first step in the risk management process
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
OrganizationalClimate
ORGANIZATIONALINFLUENCES
ORGANIZATIONALCLIMATE Structure Policies Culture
JSSC, 1998 HFACS - The first step in the risk management process
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
OperationalProcess
ORGANIZATIONALINFLUENCES
OPERATIONALPROCESS Operations Procedures Oversight
JSSC, 1998 HFACS - The first step in the risk management process
Errors
PerceptualErrors
Skill-BasedErrors
UNSAFEACTS
Errors
DecisionErrors
ExceptionalRoutine
Violations
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
Substandard Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Substandard Conditions of
Operators
PRECONDITIONSFOR
UNSAFE ACTS
Adverse Physiological
States
Physical/Mental
Limitations
Adverse Mental States
Adverse Mental States
Personal Readiness
Interpersonal Resource
Mismanagement
Substandard Practices of Operators
ResourceManagement
OrganizationalClimate
OrganizationalProcess
ORGANIZATIONALINFLUENCES
JSSC, 1998 HFACS - The first step in the risk management process
““Whenever we talk about a pilot who has been Whenever we talk about a pilot who has been killed in a flying accident, we should all keep one killed in a flying accident, we should all keep one thing in mind. He...made a judgment. He thing in mind. He...made a judgment. He believed in it so strongly that he knowingly bet believed in it so strongly that he knowingly bet his life on it. That his judgment was faulty is a his life on it. That his judgment was faulty is a tragedy,…tragedy,…
Every instructor, supervisor, and contemporary Every instructor, supervisor, and contemporary who ever spoke to him had the opportunity to who ever spoke to him had the opportunity to influence his judgement, so a little bit of all of us influence his judgement, so a little bit of all of us goes with every pilot we lose.” --goes with every pilot we lose.” --AnonymousAnonymous