Event Review Using HFACS (Template) Instructor(s) Name(s) Date

Human Error What does this phrase mean to you? If, for example, you read in the newspaper that “pilot error” was the reason for a plane crash, what would you think? Would you really understand what happened? Errare humanum est – to err is human (Plutarch, c. 100 AD).

Performance Objectives List and describe 4 levels of failure using the Human Factor Analysis and Classification System (HFACS), Given a description of an event from INSERT DATE OF EVENT, use HFACS to identify error types presented during that event, ADD ADDITIONAL PERFORMANCE OBJECTIVES FOR THE COURSE AS NEEDED, INSERT EVENT SPECIFIC PERFORMANCE OBJECTIVES FOR THE COURSE, and Given a description of an event from INSERT DATE OF EVENT, identify the relevant INSERT RELEVANT STANDARDS OR PROCEDURES. In this event review, we will use the Human Factors Analysis and Classification System (HFACS) described by Wiegmann and Shappell (2003) as a tool to identify error types that were present at the time of the event. HFACS was chosen for this exercise because it is a robust system, which is the basis for cause analysis systems used by the U.S. Department of Energy and in NERC’s Event Analysis system.

Reminder Event reviews and human factor analysis exercises are designed to further our understanding of event causes and prevent similar incidents from happening in the future. Event reviews and human factor analysis exercises are NOT about assigning blame.

Human Factors Analysis and Classification System (HFACS) Overview Organizational Influences Unsafe Supervision Preconditions of Unsafe Acts Unsafe Acts In his book, Human Error, James Reason (1990) used layers of swiss cheese as a model to describe human performance issues and error prevention.   In short, Reason said that we place defenses (the layers of cheese) between hazards in our workplace and the accidents they produce. But, none of these defenses are completely effective (there are holes in the cheese) and when the holes in the cheese align we will have a problem. Douglas Wiegmann and Scott Shappell (2003) adapted the Swiss Cheese model when they created HFACS and added descriptions for the holes in the cheese. They said that Reason did not provide a description for the holes and that such descriptions are required if you want to understand the cause of an accident and create an effective intervention strategy for the future. Wiegmann and Shappell named four levels (shown above), or layers of cheese. These are shown in greater detail on the pages that follow. Source: Douglas Wiegmann and Scott Shappell (2003), adapted from James Reason (1990)

Unsafe Acts Unsafe Acts Errors Violations Skill-based Errors Decision Errors Perceptual Errors Routine Exceptional

Preconditions of Unsafe Acts Environmental Factors Personnel Factors Physical Environment Technological Environment Crew Resource Management Personal Readiness Conditions of Operators Adverse Mental States Adverse Physiological States Physical / Mental Limitations

Unsafe Supervision Unsafe Supervision Inadequate Supervision Planned Inappropriate Operations Failure to Correct Problem Supervisory Violations

Organizational Influences Resource Management Organizational Climate Organizational Process

Event Details DESCRIBE THE EVENT IN DETAIL (JUST THE FACTS, NO OPINIONS OR CONCLUSIONS)

Additional Information PROVIDE ANY ADDITIONAL INFORMATION THAT MIGHT APPLY TO THE EVENT, RELATED TOOLS, ASSOCIATED PROCEDURES, ETC., THAT MAY PROVIDE CONTEXT FOR THE EVENT (JUST THE FACTS, NO OPINIONS)

Review Exercise Instructions Use the INSERT EXERCISE DOCUMENT NAME Use the event description and the worksheet to identify all of the error types that were present in this event. The worksheet is divided into 4 sections (one for each of the levels in the HFACS model). Place a check mark in the column on the right for each of the categories, and subcategories, that you believe were factors in this event. For each section, write down the reason(s) you chose a category or subcategory in that section. Be prepared to share your thoughts with the class.

Group Exercise – Answered(?) USE THIS PAGE TO DESCRIBE THE TRAINING TEAM MEMBERS THAT ORIGINALLY REVIEWED THE EVENT AND LIST THE HFACS CATEGORIES THAT THEY AGREED WERE CONTRIBUTIING FACTORS FOR THE EVENT.

Standards and Procedures Which standards apply to this event? Was there a violation?

Questions?

Course Quiz You must achieve a grade of 80% on this quiz to Master this course material.

Quiz Question 1 Name the 4 levels of failure included in HFACS. Unsafe Acts Preconditions of Unsafe Acts Unsafe Supervision Organizational Influences

Quiz Question 2 ADD A QUESTION ABOUT APPLICABLE STANDARDS OR PROCEDURES ADD THE ANSWER TO THIS QUESTION HERE AND INCLUDE ANY ADDITIONAL INFORMATION TO EXPLAIN THE ANSWER

Quiz Question 3 Which of the following is NOT a type of decision error? Exceeded ability Failure to correct known problem Inappropriate procedure Knowledge of the procedure was LTA This (b) is a type of Organizational Influence found in the list of Equipment/Facility Resource errors.

Quiz Question 4 ADD MORE QUESTIONS (ONE PER SLIDE) REGARDING THE EVENT THAT WAS REVIEWED, HFACS, OR RELATED TOPICS AND PLACE THE CORRECT ANSWER ON EACH SLIDE BELOW THE QUESTION (INCLUDE EXPLANATIONS FOR EACH ANSWER IF NEEDED).

Thank you