DoD-HFACS: An Introduction - EAGOSHeagosh.org/.../hfacs_ltcol_anthony_wurmstein_usaf.pdf · 2014....
Transcript of DoD-HFACS: An Introduction - EAGOSHeagosh.org/.../hfacs_ltcol_anthony_wurmstein_usaf.pdf · 2014....
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Headquarters U.S. Air Forces in Europe
DoD-HFACS:An Introduction
Lt Col Anthony WurmsteinChief, Human Factors Investigation
USAFE Flight Safety
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DoD-HFACS Topics
n Development and Philosophy
n What It Looks Like
n How It s Used
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DoD-HFACS:Overview
n A standard set of definitions of human factors and system failuresorganized into a taxonomy of system failure.
n Based on Human Factors Analysis and Classification System (HFACS)by Doug Weigmann & Scott Shappell
n Categorization of system failure in complex systemsn Latent Failuresn Active Failures
n Brings together human factors, Operations, humans systems, systemssafety and Engineering Issuesn Man, Machine, Medium, Mission, Management
n Philosophy of mishap analysis that focuses on the system instead of theindividual
n DoD-HFACS is foundation of new Air Force Safety Automated System(AFSAS) HF module
n HF data will be required for certain report classes across safetyspectrum
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Roles of HFACS
n Investigation Guide
n Database Structure
n Analysis Format
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What HFACS is
n Model of system failure in large, complex systems
n Based on science and accepted models
n Philosophy of mishap analysisn Focuses on the system instead of the individual
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What HFACS isn
n It s not a crutch for the lazy investigator
n It s not pre-loaded with solutions
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Accident & InjuryAccident & Injury
Latent Conditions
Latent Conditions
Latent Conditions
Active Conditions
Failed orAbsent Defenses
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
After Reason (1990)
HAZARDHAZARD
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Ok, So what does it looklike???
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Resource/AcquisitionManagement
Organizational Climate Organizational Process
ORGANIZATIONALINFLUENCES
InadequateSupervision
Planned InappropriateOperations
Failure to CorrectKnown Problem
Supervisory Violations
SUPERVISION
Skill-BasedErrors
Judgement &Decision-Making Errors
MisperceptionErrors
Errors Violations
ACTS
PhysicalEnvironment
TechnologicalEnvironment
Environmental Factors
Physical/MentalLimitations
Cognitive Factors Adverse PhysiolStates
Psycho-BehavioralFactors
Perceptual Factors
Condition of Individuals
Crew ResourceMangement
Self Imposed Stress
Personnel Factors
PRECONDITIONS
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Skill-BasedErrorsAE1xx
Judgement &Decision-Making Errors
AE2xx
MisperceptionErrorsAE3xx
ErrorsAE0xx
ViolationsAV0xx
ACTS
AE201 Risk Assessment During Operation
AE202 Task Misprioritization
AE203 Necessary Action - Rushed
AE204 Necessary Action - Delayed
AE205 Caution/Warning Ignored
AE206 Decision-Making During Operation
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PC101 Inattention
PC102 Channelized Attention
PC103 Cognitive Task Oversaturation
PC104 Confusion
PC105 Negative Transfer
PC106 Distraction
PC107 Geographic Misorientation (Lost)
PC108 Checklist Interference
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InadequateSupervision
SI0xx
Planned InappropriateOperations
SP0xx
Failure to CorrectKnown Problem
SF0xx
Supervisory ViolationsSV0xx
SUPERVISION
SI001 Leadership/Supervision/Oversight Inadequate
SI002 Supervision - Modeling
SI003 Local Training Issues/Programs
SI004 Supervision Policy
SI005 Supervision Personality Conflict
SI006 Supervision Lack of Feedback
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Resource/Acquisition ManagementOR0xx
Organizational ClimateOC0xx
Organizational ProcessOP0xx
ORGANIZATIONAL INFLUENCES
OC001 Unit/Organizational Values/Culture
OC002 Evaluation/Promotion/Upgrade
OC003 Perceptions of Equipment
OC004 Unit Mission/Aircraft/Vehicle/Equipment Change or Unit Deactivation
OC005 Organizational Structure
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All models are wrong, butsome are useful.
George Box (1979)
George is right.Wurmy (2004)
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Questions?
To access the DoD HFACS Guide go to:
www.safetycenter.navy.mil/hfacs/downloads/hfacs.pdf
Or
Google:
DoD HFACS
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Headquarters U.S. Air Forces in Europe
BACKUP SLIDES FOLLOW
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Headquarters U.S. Air Forces in Europe
HFACS - The Painful Details
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Resource/Acquisition ManagementOR0xx
Organizational ClimateOC0xx
Organizational ProcessOP0xx
ORGANIZATIONAL INFLUENCES
OR001 Air Traffic Control
OR002 Airfield Resources
OR003 Operator Support
OR004 Acquisition Policies/Design Processes
OR005 Attrition Policies
OR006 Accession/Selection Policies
OR007 Personnel Resources
OR008 Information Resources/Support
OR009 Financial Resources/Support
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Resource/Acquisition ManagementOR0xx
Organizational ClimateOC0xx
Organizational ProcessOP0xx
ORGANIZATIONAL INFLUENCES
OP001 Ops Tempo/Workload
OP002 Program and Policy Risk Assessment
OP003 Procedural Guidance/Publications
OP004 Organizational Training Issues/Programs
OP005 Doctrine
OP006 Program Oversight/Program Management
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InadequateSupervision
SI0xx
Planned InappropriateOperations
SP0xx
Failure to CorrectKnown Problem
SF0xx
Supervisory ViolationsSV0xx
SUPERVISION
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InadequateSupervision
SI0xx
Planned InappropriateOperations
SP0xx
Failure to CorrectKnown Problem
SF0xx
Supervisory ViolationsSV0xx
SUPERVISION
SP001 Ordered/Led on Mission Beyond Capability
SP002 Crew/Flight Makeup/Composition
SP003 Limited Recent Experience
SP004 Limited Total Experience
SP005 Proficiency
SP006 Risk Assessment Formal
SP007 Authorized Unnecessary Hazard
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InadequateSupervision
SI0xx
Planned InappropriateOperations
SP0xx
Failure to CorrectKnown Problem
SF0xx
Supervisory ViolationsSV0xx
SUPERVISION
SF001 Personnel Management
SF002 Operations Management
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InadequateSupervision
SI0xx
Planned InappropriateOperations
SP0xx
Failure to CorrectKnown Problem
SF0xx
Supervisory ViolationsSV0xx
SUPERVISION
SV001 Supervision - Discipline Enforcement
SV002 Supervision - Defacto Policy
SV003 Directed Violation
SV004 Currency
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PE101 Vision Restricted by Icing/Windows Fogged/Etc
PE102 Vision Restricted by Meteorological Conditions
PE103 Vibration
PE104 Vision Restricted in Workspace by Dust/Smoke/Etc
PE105 Windblast
PE106 Thermal Stress - Cold
PE107 Thermal Stress - Heat
PE108 Maneuvering Forces - In-flight
PE109 Lighting of Other Aircraft/Vehicle
PE110 Noise Interference
PE111 Brownout/Whiteout
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PE201 Seating and Restraints
PE202 Instrumentation and Sensory Feedback Systems
PE203 Visibility Restrictions
PE204 Controls and Switches
PE205 Automation
PE206 Workspace Incompatible with Human
PE207 Personal Equipment Interference
PE208 Communications - Equipment
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PC201 Pre-Existing Personality Disorder
PC202 Pre-Existing Psychological Disorder
PC203 Pre-Existing Psychosocial Problem
PC204 Emotional State
PC205 Personality Style
PC206 Overconfidence
PC207 Pressing
PC208 Complacency
PC209 Inadequate Motivation
PC210 Misplaced Motivation
PC211 Overaggressive
PC212 Excessive Motivation to Succeed
PC213 Get-Home-Itis / Get-There-Itis
PC214 Response Set
PC215 Motivational Exhaustion
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PC301 Effects of G-Forces (GLOC, Etc)
PC302 Prescribed Drugs
PC303 Operational Injury/Illness
PC304 Sudden Incapacitation/Unconsciousness
PC305 Pre-Existing Illness/Injury/Deficit
PC306 Physical Fatigue
PC307 Fatigue Physiological/Mental
PC308 Circadian Rhythm Desynchrony
PC309 Motion Sickness
PC310 Trapped Gas Disorders
PC311 Evolved Gas Disorders
PC312 Hypoxia
PC313 Hyperventilation
PC314 Visual Adaptation
PC315 Dehydration
PC316 Physical Task Oversaturation
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PC401 Learning Ability/Rate
PC402 Memory Ability/Lapses
PC403 Anthropometric/Biomechanical Limitations
PC404 Motor Skill/Coordination or Timing Deficiency
PC405 Technical/Procedural Knowledge
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PC501 Illusion - Kinesthetic
PC502 Illusion - Vestibular
PC503 Illusion - Visual
PC504 Misperception of Operational Conditions
PC505 Misinterpreted/Misread Instruments
PC506 Expectancy
PC507 Auditory Cues
PC508 Spatial Disorientation Type 1
PC509 Spatial Disorientation Type 2
PC510 Spatial Disorientation Type 3
PC511 Temporal Distortion
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PP101 Crew/Team Leadership
PP102 Cross-Monitoring Performance
PP103 Task Delegation
PP104 Rank/Position Authority Gradient
PP105 Assertiveness
PP106 Communication Critical Information
PP107 Standard/Proper Terminology
PP108 Challenge and Reply
PP109 Mission Planning
PP110 Mission Briefing
PP111 Task/Mission-In-Progress Re-Planning
PP112 Miscommunication
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PhysicalEnvironment
PE1xx
TechnologicalEnvironment
PE2xx
Environmental FactorsPE0xx
Cognitive FactorsPC1xx
Psycho-BehavioralFactorsPC2xx
Adverse PhysiolStatesPC3xx
Physical/MentalLimitations
PC4xx
Perceptual FactorsPC5xx
Condition of IndividualsPC0xx
Crew ResourceManagement
PP1XX
Self Imposed StressPP2xx
Personnel FactorsPP0xx
PRECONDITIONS
PP201 Physical Fitness
PP202 Alcohol
PP203 Drugs/Supplements/Self Medication
PP204 Nutrition
PP205 Inadequate Rest
PP206 Unreported Disqualifying Medical Condition
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Skill-BasedErrorsAE1xx
Judgement &Decision-Making Errors
AE2xx
MisperceptionErrorsAE3xx
ErrorsAE0xx
ViolationsAV0xx
ACTS
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Skill-BasedErrorsAE1xx
Judgement &Decision-Making Errors
AE2xx
MisperceptionErrorsAE3xx
ErrorsAE0xx
ViolationsAV0xx
ACTS
AE101 Inadvertent Operation
AE102 Checklist Error
AE103 Procedural Error
AE104 Overcontrol/Undercontrol
AE105 Breakdown in Visual Scan
AE106 Inadequate Anti-G Straining Maneuver
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Skill-BasedErrorsAE1xx
Judgement &Decision-Making Errors
AE2xx
MisperceptionErrorsAE3xx
ErrorsAE0xx
ViolationsAV0xx
ACTS
AE301 Error Due to Misperception
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Skill-BasedErrorsAE1xx
Judgement &Decision-Making Errors
AE2xx
MisperceptionErrorsAE3xx
ErrorsAE0xx
ViolationsAV0xx
ACTS
AV001 Violation Based on Risk Assessment
AV002 Violation Routine/Widespread
AV003 Violation Lack of Discipline
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Headquarters U.S. Air Forces in Europe
HFACS As An InvestigationSystem
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Accident & InjuryAccident & Injury
Latent Conditions
Latent Conditions
Latent Conditions
Active Conditions
Failed orAbsent Defenses
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
After Reason (1990)
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Applying HFACSThe USN Analysis Process
Event / Mishap-Centric Concept
Wingman
HFACSSq/CC
Wing/CC
MAJCOM/CC
MP
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Applying HFACSThe USN Analysis Process
Event / Mishap-Centric ConceptW/HFACS MX
Wingman
HFACSSq/CC
Wing/CC
MAJCOM/CC
HFACSMX
MxMP
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Wurmstein 2004
Acts of Mx
Acts ofATC
Acts ofOperators
Preconditions
Supervision
Acts ofSOF
Acts of DO
AcquisitionPolicies
AccessionPolicies
Supervision
QA System
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Applying HFACSPerson-Centric Investigation Process
Person-Centric Concept
HFACS
HFACS
HFACS
HFACSHFACS
MPWingman
HFACSMx
Mx
Sq/CC
Wing/CC
MAJCOM/CC
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Applying HFACSThe USAF Investigation Process
MPMx Wingman
Sq/CC
Wing/CC
MAJCOM/CC
Preconditions
Acts
Supervisory
Organizational
ATC
Sq/CC
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Applying HFACSGround Mishap
MishapCE Tech
ShiftSuper
TransportationJourneyman
Sq/CC
Wing/CC
MAJCOM/CC
Preconditions
Acts
Supervisory
Organizational
Dispatch
Sq/CC
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Applying HFACSSplit Concept Investigation Process
Split Concept
MP
Mx
Wingman
Sq/CC
Wing/CC
MAJCOM/CC
Preconditions
Acts
Supervisory
Organizational
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Headquarters U.S. Air Forces in Europe
HFACS Case Study
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OP002
Organizational
Supervision
Preconditions
Acts
SP006
PC503
PC208
PE202
AE202AE301
PC508