HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) THE FIRST STEP IN THE RISK MANAGEMENT PROCESS

“Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

NAVAL AVIATION MISHAP RATE Class A Mishaps/100,000 Flight Hours FY 50-96 776 aircraft destroyed in 1954 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 39 aircraft destroyed in 1996 50 40 Class A Mishaps/100,000 Flight Hours 30 20 2.39 10 50 65 80 96 Fiscal Year

Class A, B,& C Mishaps/100,000 Flight Hours All NAVY/MARINE Class A, B, & C Mishaps 16 14 12 Human 10 Class A, B,& C Mishaps/100,000 Flight Hours 8 6 4 Mechanical 2 1977 1979 1981 1983 1985 1987 1989 1991 Year Shappell & Wiegmann, 1996

Active versus Latent Failures (Reason, 1990) Unsafe Acts Active Conditions Failed to Scan Instruments Penetrated IMC when VMC only Failed or Absent Defenses

Active versus Latent Failures (Reason, 1990) Preconditions for Unsafe Acts Latent Conditions Poor CRM Mental Fatigue Unsafe Acts Active Conditions Failed to Scan Instruments Penetrated IMC when VMC only Failed or Absent Defenses

Active versus Latent Failures (Reason, 1990) Unsafe Supervision Latent Conditions Deficient training program Improper crew pairing Preconditions for Unsafe Acts Latent Conditions Poor CRM Mental Fatigue Unsafe Acts Active Conditions Failed to Scan Instruments Penetrated IMC when VMC only Failed or Absent Defenses

Active versus Latent Failures (Reason, 1990) Organizational Factors Latent Conditions Excessive cost cutting Inadequate promotion policies Unsafe Supervision Latent Conditions Deficient training program Improper crew pairing Preconditions for Unsafe Acts Latent Conditions Poor CRM Mental Fatigue Unsafe Acts Active Conditions Failed to Scan Instruments Penetrated IMC when VMC only Failed or Absent Defenses Accident & Injury Crashed into side of mountain

UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors Decision Skill-Based Unsafe Acts

DECISION ERROR UNSAFE ACTS Errors Decision UNSAFE ACTS Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional DECISION ERROR Rule-based Decisions - If X, then do Y - Highly Procedural Choice Decisions - Knowledge-based Ill-Structured Decisions - Problem solving Unsafe Acts

SKILL-BASED ERRORS UNSAFE ACTS Errors Skill-Based UNSAFE ACTS Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional SKILL-BASED ERRORS Unsafe Acts 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

PERCEPTUAL ERRORS UNSAFE ACTS Errors Perceptual UNSAFE ACTS Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional PERCEPTUAL ERRORS Unsafe Acts Misjudge Distance, Altitude, Airspeed Spatial Disorientation Visual Illusions

ROUTINE (INFRACTIONS) Violations Routine UNSAFE ACTS Violations Routine UNSAFE ACTS Errors Decision Errors Skill-Based Errors Perceptual Errors Exceptional 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 Unsafe Acts

(Isolated departures from the rules not condoned Violations Exceptional UNSAFE ACTS Violations Exceptional UNSAFE ACTS Errors Decision Errors Skill-Based Errors Perceptual Errors Routine Exceptional EXCEPTIONAL (Isolated departures from the rules not condoned by management) Unsafe Acts 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

Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Preconditions for Unsafe Acts Unsafe Acts

Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Mental States PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators Substandard Practices of Operators Adverse Mental States Adverse Physiological States Physical/ Mental Limitations Crew Resource Mismanagement Personal Readiness ADVERSE MENTAL STATE Preconditions for Unsafe Acts Unsafe Acts Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation

ADVERSE PHYSIOLOGICAL STATES Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States ADVERSE PHYSIOLOGICAL STATES Preconditions for Unsafe Acts Unsafe Acts G-induced Loss of Consciousness Hypoxia Motion Sickness Medical Illness Intoxication

PHYSICAL/MENTAL LIMITATIONS Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Physical/ Mental Limitations PHYSICAL/MENTAL LIMITATIONS Preconditions for Unsafe Acts Unsafe Acts Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude

CREW RESOURCE MISMANAGEMENT PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Interpersonal Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Crew Resource Mismanagement CREW RESOURCE MISMANAGEMENT Preconditions for Unsafe Acts Unsafe Acts Not Working as a Team Poor Aircrew Coordination Improper Briefing Before a Mission Inadequate Coordination of Flight

PERSONAL READINESS Substandard Conditions of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness Crew Resource Mismanagement Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Personal Readiness PERSONAL READINESS Preconditions for Unsafe Acts Unsafe Acts Readiness Violations Crew Rest Requirements Bottle-to-Brief Rules Self-Medicating Poor Judgement Poor Dietary Practices Overexertion While Off Duty Excessive “Voluntary” PT

UNSAFE SUPERVISION Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations Unsafe Supervision Preconditions for Unsafe Acts Acts

INADEQUATE SUPERVISION UNSAFE SUPERVISION Inadequate Supervision UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Inadequate Supervision Supervisory Violations INADEQUATE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Acts Failure to Administer Proper Training Lack of Professional Guidance

PLANNED INAPPROPRIATE UNSAFE SUPERVISION Planned Inappropriate Operations UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Inadequate Supervision Supervisory Violations PLANNED INAPPROPRIATE OPERATIONS Unsafe Supervision Preconditions for Unsafe Acts Acts Mission Risk without Benefit Improper Work Tempo Poor Crew Pairing

FAILED TO CORRECT A KNOWN PROBLEM UNSAFE SUPERVISION UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Inadequate Supervision Supervisory Violations FAILED TO CORRECT A KNOWN PROBLEM Unsafe Supervision Preconditions for Unsafe Acts Acts Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard

SUPERVISORY VIOLATIONS UNSAFE SUPERVISION UNSAFE SUPERVISION Planned Inappropriate Operations Failed to Correct Problem Inadequate Supervision Supervisory Violations SUPERVISORY VIOLATIONS Unsafe Supervision Preconditions for Unsafe Acts Acts Not Adhering to Rules and Regulations Willful Disregard for Authority by Supervisors

ORGANIZATIONAL INFLUENCES Resource Organizational Operational Climate Resource Management Operational Process Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Acts

RESOURCE MANAGEMENT Organizational Climate Resource Management Operational Process ORGANIZATIONAL INFLUENCES Resource Management ORGANIZATIONAL INFLUENCES RESOURCE MANAGEMENT Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Acts Human Monetary Equipment/Facility

ORGANIZATIONAL CLIMATE Resource Management Operational Process ORGANIZATIONAL INFLUENCES Organizational Climate ORGANIZATIONAL INFLUENCES ORGANIZATIONAL CLIMATE Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Acts Structure Policies Culture

OPERATIONAL PROCESS Organizational Climate Resource Management INFLUENCES Operational Process ORGANIZATIONAL INFLUENCES OPERATIONAL PROCESS Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Acts Operations Procedures Oversight

Resource Management Organizational Climate Process ORGANIZATIONAL INFLUENCES Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS What my guys at the Safety Center did was define the holes in the cheese using a classification system they call the Human Factors Analysis and Classification System (HFACS). Now before you get all excited, we don’t expect you to know all the inner workings of HFACS -- just be familiar with the concept. Your Flight Surgeon has had extensive training on this investigative tool while training at NOMI (some of you may remember it as NAMI). He/she will be your subject matter experts in the field, during briefs and God forbid, during mishap investigations. What I want you to understand now is that we view HFACS as the first step in the risk management process -- The identification of hazards. We have had tremendous success using this tool already. Notice that my folks have defined the holes at each level. Peeling the human factors onion back until we can get at the root of the problem. Take the Unsafe Acts of Aircrew level for instance. Unsafe Acts can be broken down into to two general categories: Errors and Violations. Now we all know what violations are and we would like to believe that they don’t occur often. But let me tell you, 40% of all Naval aviation mishaps associated with Human Factors have violations associated with them. Not surprisingly, aircrew error is identified in nearly all Naval aviation mishaps as well (often as the last fatal flaw in the chain of events). But that’s NOT where the fix is (or to use risk management terms) where the controls should be placed. The fix is higher in the system at the precondition, supervisory and organizational level. For instance, it’s not surprising that with current fiscal constraints and down-sizing the human, material and monetary assets are lacking to maintain proficiency. Consequently, supervisors are being forced to “do more with less” leading to poor crew pairing and overworked crews and maintainers. This leads to mental fatigue which will ultimately lead to errors in the cockpit! Where’s the fix? Certainly not at the flight crew level. We’ve been aiming at the aircrew for years and haven’t made a dent. We will have to focus higher in the system if we want to effect change. This is what HFACS brings to the table. It’s not another program or requirement to be shouldered by the Line. It’s a tool to assist you in identifying and controlling hazards. Be familiar with it! Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Personal Readiness Interpersonal Resource Mismanagement Substandard Practices of Operators Errors Perceptual Skill-Based UNSAFE ACTS Decision Exceptional Routine Violations

“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