2. 1 Human Factors Theory Update 1 July 2014

3. 2 34 This can only happen with the human element present – The question is why ????

4. INTRODUCTION TO HUMAN FACTORS ACCIDENT INVESTIGATION AND PREVENTION

5. 4  It is not surprising then, that human error has been implicated in 60-80% of accidents in aviation and other complex systems.  In fact, while accidents solely attributable to environmental and mechanical factors have been greatly reduced over the last several years, those attributable to human error continue to plague organizations. “Human beings by their very nature make mistakes; therefore, it is unreasonable to expect error-free human performance.” Shappell & Wiegmann, 1997

6. 5 Why Investigate the Human Factor People Make Mistakes! Leading cause of accidents. DA Pam 385-40 Army Accident Investigation and Reporting –Materiel Factors –Environmental Factors –Human Factors  System Inadequacies (figure 2-1) Support Standards Training Leader Individual

7. 6 Human Factors: A Brief History Human factors is a discipline that has grown over the past 120 years. Early Safety Philosophy Heinricks Theory The people had a voice – Union Accident Investigation required an in depth study

8. 7 What are Human Factors Fatigue, Body Rhythms and Sleep Fitness and Performance (Age) Vision and Visual Illusions Motivation and Leadership Communications, Language and Speech Attitudes and Persuasion Training and Training Devices Documentation Displays and Controls Space and Layout Education and Application

9. 8 Organizational Factors Unsafe Supervision Preconditions Unsafe Acts Where do we usually look to prevent accidents?

10. 9 Organizational Failures Unsafe Supervision Preconditions Unsafe Acts Where should we look to prevent accidents? Operating Environment

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12. 11 Ergonomics Medical Issues Organizational Factors CRM Human Error A comprehensive Human Factors Analysis and Classification System (HFACS) has been developed to help put all these pieces together.

13. 12 A HUMAN FACTORS APPROACH TO ACCIDENT ANALYSIS AND PREVENTION Scott Shappell, Ph.D. Civil Aeromedical Institute Douglas Wiegmann, Ph.D. University of Illinois

14. 13 Wiegmann-Shappell Human Factors Analysis And Classification System (HFACS) OPNAV 3750.6R (Appendix O) Naval Safety Center 375 A Street Norfolk VA 23511-4399 (757) 444-3520

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16. 15 Errors Perceptual Errors Skill-Based Errors UNSAFE ACTS Errors Decision Errors Exceptional Routine Violations Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Personal Readiness Crew Resource Mismanagement Substandard Practices of Operators Resource Management Organizational Climate Organizational Process ORGANIZATIONAL INFLUENCES UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations

17. 16 Unsafe Acts UNSAFE ACTS UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors Skill-based Errors Decision Errors 80%

18. 17 Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Decision Error Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Skill-Based Errors SKILL-BASED ERROR  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  Execution Failures - over/under reacting/controlling - 5 Points of Performance/PLF

19. 18 Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Skill-based Errors Skill-Based Errors Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Decision Errors DECISION ERRORS  Rule-based Decisions - If X, then do Y - Highly Procedural  Choice Decisions - Knowledge-based  Ill-Structured Decisions - Problem solving

20. 19 Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Skill-Based Errors Decision Error Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors PERCEPTUAL ERRORS  Misjudge Distance, Altitude, Airspeed, Groundspeed, Azimuth  Spatial Disorientation  Visual Illusions

21. 20 Exceptional Violations Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts Violations Routine UNSAFE ACTS UNSAFE ACTS ROUTINE (INFRACTIONS) (Habitual departures from rules condoned by management) ä Violation of Orders/Regulations/SOP - Failed to Inspect Vehicle after Caution Light - Violated Squadron SOP Restricting Flight Below 500’ - Failed to Comply w/-10 load plan or warnings - Conducted Maintenance Mission with PAX - Elected to File VFR in Marginal Weather Conditions - Took Red- X ed Vehicle without Dispatch - Inadequate Brief and Limits on Mission - TC Knowingly Accepted Non-Current Crew ä Failed to Adhere to Brief ä Not Current/Qualified for Mission/No Driver’s License ä Improper Procedure

22. 21 Routine Violations Exceptional UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts Exceptional Violations Exceptional UNSAFE ACTS UNSAFE ACTS EXCEPTIONAL (Isolated departures from the rules not condoned by management) ä Violated Orders/Regulations/SOP - Performed Unauthorized Acrobatic Maneuver - Speeding in Vehicle - Failed to Complete Performance Computations for Flight - Improper Takeoff Technique - Failed to Obtain Valid Weather Brief ä Accepted Unnecessary Hazard ä Not Current/Qualified for Mission ä Exceeded Limits of Aircraft/Vehicle

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24. 23 PRECONDITIONS FOR UNSAFE ACTS Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators

25. 24 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators ADVERSE MENTAL STATE  Loss of Situational Awareness  Circadian dysrhythmia - Sleep  Alertness (Drowsiness)  Overconfidence  Complacency  Task Fixation PRECONDITIONS FOR UNSAFE ACTS 80% Unsafe Acts Dig Deeper

26. 25 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators ADVERSE PHYSIOLOGICAL STATES  Medication  Hypoxia  Motion Sickness  Medical Illness  Intoxication PRECONDITIONS FOR UNSAFE ACTS

27. 26 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators PHYSICAL/MENTAL LIMITATIONS  Lack of Sensory Input  Limited Reaction Time  Incompatible Physical Capabilities  Incompatible Intelligence/Aptitude PRECONDITIONS FOR UNSAFE ACTS

28. 27 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators CREW RESOURCE MANAGEMENT  Not Working as a Team  Poor Crew Coordination  Improper Briefing Before a Mission  Inadequate Coordination of Mission PRECONDITIONS FOR UNSAFE ACTS Big Problem in Aviation Need Good Communication Skills

29. 28 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Supervisory Crew Rank Gradient SUPERVISORY

30. 29 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Supervisory Crew Rank Gradient CREW 1972 Florida Everglades crash 20 cent light bulb

31. 30 Eastern Airlines Flight 401 Crashed Florida Everglades Lockheed L-1011 (101 Deaths)

32. 31 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Supervisory Crew Rank Gradient RANK GRADIENT Washington, DC Jan 1982 Pilot failed to listen to Copilot Crash into the Potomac River

33. 32 Air Florida Flight 90 Crashed into the Potomac River Boeing 737-300 (74 Deaths)

34. 33 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators NON-SUPERVISORY TOLERANCE  Failure to report incidents of misconduct  Toleration of unsafe acts and behaviors PRECONDITIONS FOR UNSAFE ACTS

35. 34 Preconditions for Unsafe Acts Unsafe Acts Physical/ Mental Limitations Physical/ Mental Limitations Non-Supervisory Tolerance of Unsafe Acts Non-Supervisory Tolerance of Unsafe Acts Crew Resource Management Crew Resource Management Personal Readiness Personal Readiness Adverse Physiological States Adverse Physiological States Adverse Mental States Adverse Mental States Substandard Conditions of Operators Substandard Conditions of Operators Substandard Practices of Operators Substandard Practices of Operators PERSONAL READINESS Readiness Violations  Crew Rest Requirements  Bottle-to-Brief Rules  Self-Medicating Poor Judgement  Poor Dietary Practices  Overexertion While Off Duty  Excessive “Voluntary” PT PRECONDITIONS FOR UNSAFE ACTS

36. 35 Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations While empowering individuals to make decisions and function independently is certainly essential, this does not divorce the Leader from accountability

37. 36 UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations UNRECOGNIZED HAZARDOUS OPERATIONS  Loss of Supervisory Situational Awareness “Don’t Know What You Don’t Know”  Hazards go unseen/unrecognized  Supervisor is over-tasked / untrained  No mentorship / role model

38. 37 UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations INADEQUATE DOCUMENTAION/ PROCEDURES  Failure of standards  No Standards  Recognized “after the fact”

39. 38 UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations INADEQUATE SUPERVISION  Failure to Administer Proper Training  Lack of Professional Guidance/Mentor

40. 39 UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations PLANNED INAPPROPRIATE OPERATIONS  Mission Risk without Benefit  Improper Work Tempo  Poor Crew Pairing  Poor Planning by Leaders

41. 40 UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations FAILED TO CORRECT A KNOWN PROBLEM  Failure to Correct Inappropriate Behavior  Failure to Correct a Safety Hazard

42. 41 UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations SUPERVISORY VIOLATIONS  Not Adhering to Rules and Regulations  Willful Disregard for Authority by Supervisors

43. 42 Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES

44. 43 Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES Resource Management Resource Management ORGANIZATIONAL INFLUENCES RESOURCE MANAGEMENT  Human  Monetary  Equipment/Facility

45. 44 Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES Organizational Climate ORGANIZATIONAL INFLUENCES ORGANIZATIONAL CLIMATE  Structure  Policies  Culture

46. 45 Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES Operational Process ORGANIZATIONAL INFLUENCES OPERATIONAL PROCESS  Operations  Procedures  Oversight

47. 46 Errors Perceptual Errors Skill-Based Errors UNSAFE ACTS Errors Decision Errors Exceptional Routine Violations Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States Physical/ Mental Limitations Adverse Mental States Personal Readiness Crew Resource Mismanagement Substandard Practices of Operators Resource Management Organizational Climate Organizational Process ORGANIZATIONAL INFLUENCES UNSAFE SUPERVISION UNSAFE SUPERVISION Unforeseen Known Unrecognized Hazardous Operations Unrecognized Hazardous Operations Inadequate Documentation/ Procedures Inadequate Documentation/ Procedures Inadequate Supervision Inadequate Supervision Planned Inappropriate Operations Planned Inappropriate Operations Failure to Correct Problem Failure to Correct Problem Supervisory Violations Supervisory Violations

48. 47 HFACS provides:  A system to record and correlate causes of human failure for future prevention controls.  Over time will provides information that can be used for accident prevention !  Why holes exist ?  What we can do to prevent holes ?  Risk Management !  How can HFACS be used to prevent accidents before they occur? SUMMARY ? ?

49. 48 Organizational Influences Unsafe Supervisory Practices Preconditions for Unsafe Acts Unsafe Soldier Actions Accident n Driver’s Training Program Failure. n Failed to Correct a Known Problem. n Inadequate NCO Supervision. n Inadequate Maintenance Supervision. n Fatigue. n Inexperience. n Support Failure. n Failure to Follow Procedure. n Speeding Violation. n Driving Blind. n Driving Skill Error. Human factors at every level of the Department of the Army can influence mission outcomes for the individual soldier. When failures occur at the different levels they open windows of opportunity for the soldier to fail. A SOLDIER’S FAILURE MAY NOT BE DUE TO HIS OWN ACTIONS.

50. 49 Putting It All Together Unsafe Acts Organizational Factors Unsafe Supervision Preconditions for Unsafe Acts Present and Contributing Present but not Contributing Special Observation Unsafe Inputs to the Organization & an Unsafe Operating Environment  Wiegmann and Shappell, 1999

51. 50 Safe Acts Safe Organizational Factors Safe Supervision Preconditions for Safe Acts Plug the holes & prevent the accidents! Mission Success Safe Inputs to the Organization & a Safe Operating Environment  Wiegmann and Shappell, 1999

52. When we get it right! 51

53. When we get it right? 52

54. When we get it right? 53

55. 54 It is our belief that the Humans Factors Analysis and Classification System (HFACS) framework bridges the gap between theory and practice by providing investigators with a comprehensive, user friendly tool for identifying and classifying the human causes or aviation accidents. Shappell and Wiegmann – February 2000 Conclusion