Presentation is loading. Please wait.

Presentation is loading. Please wait.

JSSC, 1998 HFACS - The first step in the risk management process HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) THE FIRST STEP IN THE RISK MANAGEMENT.

Similar presentations


Presentation on theme: "JSSC, 1998 HFACS - The first step in the risk management process HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) THE FIRST STEP IN THE RISK MANAGEMENT."— Presentation transcript:

1 JSSC, 1998 HFACS - The first step in the risk management process HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) THE FIRST STEP IN THE RISK MANAGEMENT PROCESS

2 JSSC, 1998 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

3 JSSC, 1998 HFACS - The first step in the risk management process NAVAL AVIATION MISHAP RATE 776 aircraft destroyed in 1954 FY Fiscal Year aircraft destroyed in Angled Carrier Decks Naval Aviation Safety Center NAMP est RAG concept initiated NATOPS initiated 1961 Squadron Safety program System Safety Designated Aircraft ACT HFCs Class A Mishaps/100,000 Flight Hours

4 JSSC, 1998 HFACS - The first step in the risk management process All NAVY/MARINE Class A, B, & C Mishaps Shappell & Wiegmann, 1996 Class A, B,& C Mishaps/100,000 Flight Hours Year Mechanical Human

5 JSSC, 1998 HFACS - The first step in the risk management process Active Conditions Failed to Scan Instruments Penetrated IMC when VMC only Unsafe Acts Active versus Latent Failures (Reason, 1990) Failed or Absent Defenses

6 JSSC, 1998 HFACS - The first step in the risk management process Latent Conditions Poor CRM Mental Fatigue Active Conditions Failed to Scan Instruments Penetrated IMC when VMC only Failed or Absent Defenses Preconditions for Unsafe Acts Unsafe Acts Active versus Latent Failures (Reason, 1990)

7 JSSC, 1998 HFACS - The first step in the risk management process Latent Conditions Deficient training program Improper crew pairing Latent Conditions Poor CRM Mental Fatigue Active Conditions Failed to Scan Instruments Penetrated IMC when VMC only Failed or Absent Defenses Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Active versus Latent Failures (Reason, 1990)

8 JSSC, 1998 HFACS - The first step in the risk management process Latent Conditions Excessive cost cutting Inadequate promotion policies Latent Conditions Deficient training program Improper crew pairing Latent Conditions Poor CRM Mental Fatigue Active Conditions Failed to Scan Instruments Penetrated IMC when VMC only Failed or Absent Defenses Organizational Factors Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Accident & Injury Crashed into side of mountain Active versus Latent Failures (Reason, 1990)

9 JSSC, 1998 HFACS - The first step in the risk management process Unsafe Acts UNSAFE ACTS UNSAFE ACTS Violations Errors Exceptional Routine Perceptual Errors Decision Errors Skill-Based Errors

10 JSSC, 1998 HFACS - The first step in the risk management process Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Decision Errors DECISION ERROR Rule-based Decisions - If X, then do Y - Highly Procedural Choice Decisions - Knowledge-based Ill-Structured Decisions - Problem solving

11 JSSC, 1998 HFACS - The first step in the risk management process Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Skill-Based Errors SKILL-BASED ERRORS 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

12 JSSC, 1998 HFACS - The first step in the risk management process Violations Exceptional Routine UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors Decision Errors Skill-Based Errors Unsafe Acts UNSAFE ACTS UNSAFE ACTS Errors Perceptual Errors PERCEPTUAL ERRORS Misjudge Distance, Altitude, Airspeed Spatial Disorientation Visual Illusions

13 JSSC, 1998 HFACS - The first step in the risk management process 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 ACFT after In-Flight Caution Light - Violated Squadron SOP Restricting Flight Below 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 ä Failed to Adhere to Brief ä Not Current/Qualified for Mission ä Improper Procedure

14 JSSC, 1998 HFACS - The first step in the risk management process 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 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 ä Accepted Unnecessary Hazard ä Not Current/Qualified for Mission ä Exceeded Limits of Aircraft

15 JSSC, 1998 HFACS - The first step in the risk management process 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 Preconditions for Unsafe Acts Unsafe Acts

16 JSSC, 1998 HFACS - The first step in the risk management process Preconditions for Unsafe Acts Unsafe Acts 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 Mental States ADVERSE MENTAL STATE Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation

17 JSSC, 1998 HFACS - The first step in the risk management process 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 Preconditions for Unsafe Acts Unsafe Acts Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Adverse Physiological States ADVERSE PHYSIOLOGICAL STATES G-induced Loss of Consciousness Hypoxia Motion Sickness Medical Illness Intoxication

18 JSSC, 1998 HFACS - The first step in the risk management process 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 Preconditions for Unsafe Acts Unsafe Acts Substandard Conditions of Operators PRECONDITIONS FOR UNSAFE ACTS Physical/ Mental Limitations PHYSICAL/MENTAL LIMITATIONS Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude

19 JSSC, 1998 HFACS - The first step in the risk management process 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 Preconditions for Unsafe Acts Unsafe Acts Substandard Practices of Operators PRECONDITIONS FOR UNSAFE ACTS Crew Resource Mismanagement CREW RESOURCE MISMANAGEMENT Not Working as a Team Poor Aircrew Coordination Improper Briefing Before a Mission Inadequate Coordination of Flight

20 JSSC, 1998 HFACS - The first step in the risk management process Preconditions for Unsafe Acts Unsafe Acts 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 Readiness Violations Crew Rest Requirements Bottle-to-Brief Rules Self-Medicating Poor Judgement Poor Dietary Practices Overexertion While Off Duty Excessive Voluntary PT

21 JSSC, 1998 HFACS - The first step in the risk management process Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

22 JSSC, 1998 HFACS - The first step in the risk management process UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Inadequate Supervision INADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional Guidance

23 JSSC, 1998 HFACS - The first step in the risk management process UNSAFE SUPERVISION UNSAFE SUPERVISION Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Planned Inappropriate Operations PLANNED INAPPROPRIATE OPERATIONS Mission Risk without Benefit Improper Work Tempo Poor Crew Pairing

24 JSSC, 1998 HFACS - The first step in the risk management process Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION Failed to Correct Problem UNSAFE SUPERVISION UNSAFE SUPERVISION FAILED TO CORRECT A KNOWN PROBLEM Failure to Correct Inappropriate Behavior Failure to Correct a Safety Hazard

25 JSSC, 1998 HFACS - The first step in the risk management process Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION SUPERVISORY VIOLATIONS Not Adhering to Rules and Regulations Willful Disregard for Authority by Supervisors Supervisory Violations UNSAFE SUPERVISION UNSAFE SUPERVISION

26 JSSC, 1998 HFACS - The first step in the risk management process Organizational Influences Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Organizational Climate Resource Management Resource Management Operational Process ORGANIZATIONAL INFLUENCES

27 JSSC, 1998 HFACS - The first step in the risk management process 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

28 JSSC, 1998 HFACS - The first step in the risk management process 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

29 JSSC, 1998 HFACS - The first step in the risk management process 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

30 JSSC, 1998 HFACS - The first step in the risk management process Errors Perceptual Errors Skill-Based Errors UNSAFE ACTS Errors Decision Errors Exceptional Routine Violations Inadequate Supervision Planned Inappropriate Operations Failed to Correct Problem Supervisory Violations UNSAFE SUPERVISION 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 Interpersonal Resource Mismanagement Substandard Practices of Operators Resource Management Organizational Climate Organizational Process ORGANIZATIONAL INFLUENCES

31 JSSC, 1998 HFACS - The first step in the risk management process 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


Download ppt "JSSC, 1998 HFACS - The first step in the risk management process HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) THE FIRST STEP IN THE RISK MANAGEMENT."

Similar presentations


Ads by Google