Developing HFACS

Developing the Human Factor Analysis Classification System for the Fire Service

Ryan M. Cole

Skyland Fire Rescue Skyland, NC

Developing HFACS 2

Certification Statement I herby certify that this paper constitutes my own product, that where the language of others is

set forth, quotation marks so indicate, and that appropriate credit is given where I have used the

language, ideas, expressions or writing of another.

Signed:___________________________________

Developing HFACS 3

Abstract

The methodology of the research was based on developing a proven accident analysis

tool to identify specific, measurable, preventable causal factors affecting the fire service. The

Human Factor Analysis Classification System provides a supplement to incident and injury

investigation providing insight into human error. Unsafe acts, pre-conditions to unsafe acts,

unsafe supervision, and organizational issues are the primary areas of the Human Factor Analysis

Classification System, which provides causal factors in each area.

The causal factors identify the hazards of each area resulting in the incident occurring

which if identified could be prevented. The Human Factor Analysis Classification tool will

identify the specific data which can result in clear, concise, specific, and measurable objectives,

as it has for other industries.

Developing HFACS 4

Table of Contents

Abstract……………………………………………………………………………………………3

Table of Contents………………………………………………………………………………….4

Introduction………………………………………………………………………………………..5

Background and Significance……………………………………………………………………..6

Literature Review…………………………………………….…………………………………..11

Procedures………………………………………………….…………………………………….36

Results……………………………………………………………………………………………38

Discussion………………………………………………………………………………………..50

Recommendations………………………………………………………………………………..53

Reference List……………………………………………………………………………………57

Appendix

Appendix A (Swiss Cheese Model)..……………………………………………………………61

Appendix B (HFACS Flow Chart)………………………………………………………………62

Developing HFACS 5

Introduction

Preventing firefighter injuries and fatalities has proven to be difficult while looking at the

trends without any noticeable declines. The fire service focus on safety is more prevalent now

than any other time in history (Brunacini, 2008). Injury and fatality information is abundant with

causal factors identified in broad terminology. As identified in Firefighter Fatalities in the United

States 2007 by the National Fire Protection Association (NFPA) (2008) provides a vision of what

the natures of fatalities are such as: sudden cardiac death, burns, asphyxiation, and internal

trauma. Deaths by causes of injury are identified as: exertion or stress, struck by or contact with

object, caught or trapped, and falls (NFPA, 2008). To teach prevention, the behavior must first

be identified then it is essential that the behavior is modified or changed. The difficulty in

identifying the behaviors in the broad causes stated is evident. The identification of behaviors

must be specific and measurable to create changeable effects. Identifying specific and

measurable behaviors is utilized widely in public education; however, firefighter safety is not as

prevalent. The Human Factor Analysis Classification System (HFACS) developed by Wiegman

and Shappell (2003) was identified in previous research: Identifying a Risk Evaluation Tool to

Prevent Injuries and Fatalities by Cole (2007) as the most appropriate human error accident

evaluation tool. The HFACS identifies causal factors in unsafe acts of the individual,

preconditions of unsafe acts, unsafe supervision, and organizational influences. The HFACS

system has been developed and utilized by many industries, primarily aviation; however, it has

not been specified for the fire service. The HFACS provides categories, subcategories and causal

factors from the four primary divisions identified.

Developing HFACS 6

The previous research provided the basis for the current project to identify the necessary

changes of a proven investigation program (HFACS) utilized by the military, transportation and

aviation industry to meet the needs of the fire service. To facilitate the necessary changes the

following areas were identified as needing to be addressed:

1. What are the categories and causal factors of unsafe acts, preconditions for unsafe acts,

supervisory issues and organizational issues in the Human Factors Analysis Classification

System that affect the fire service?

2. How are uses of the Human Factor Analysis Classification System in other industries

classified and relative to the fire service?

3. How would the Human Factor Analysis Classification System be utilized to provide injury

prevention data in the fire service?

4. What advantages would the Human Factor Analysis Classification provide in the analysis of

firefighter injuries, and fatalities?

In answering the research questions, the current HFACS program will be further

evaluated to identify needs of the fire service, as well as contributory documents further

classifying the divisions, categories, subcategories, and causal factors affecting the fire service. If

successful the research will provide a path to specific measurable behaviors that can be identified

as preventable changes.

Background and Significance

Skyland Fire and Rescue currently does not utilize an accident analysis program when an

incident occurs that causes injury or property damage. Skyland as many other organizations,

conducts a formal investigation of every incident. The formal investigation identifies how the

operator failed and what the organization can do to prevent it from occurring in the future. With

Developing HFACS 7

an average of nearly six injuries per year, a total of 57injuries in a ten year period, and over a

half a million dollars in property damage, it was determined to seek a program to analyze the

cause of injuries and damage. In a previous research project Identifying a Risk Evaluation Tool

to Prevent Injuries and Fatalities (Cole 2007), the analysis tool identified to obtain the best

information providing changeable behaviors was the Human Factors Analysis Classification

System.

In North Carolina when an in line of duty death occurs, the Office of State Fire Marshal

(NCOSFM) provides assistance to families and organizations of the fallen firefighter. One of the

areas of assistance provided by NCOSFM includes collecting documentation of the incident and

providing appropriate information to federal and state officials to ensure receipt of the Public

Safety Officer Benefit. Through the collection of information NCOSFM has the most

comprehensive documentation of firefighter fatalities in North Carolina. North Carolina

experienced 57 firefighter fatalities in a ten year period from 1998 to 2008. The types of

incidents resulting in fatalities included; heart attacks at 58%, motor vehicle crashes at 28%, fires

at 9%, and other types at 9%.

The United States Fire Administration (USFA) and National Fallen Firefighters

Foundation (NFFF) provided the summit which identified the 16 Firefighter Life Safety

Initiatives in 2004. Five of the life safety initiatives will be addressed in the following research:

enhance the personal and organizational accountability for health and safety throughout the fire

service, focus greater attention on the integration of risk management with incident management

at all levels, empower all firefighters to stop unsafe practices, utilize available technology

wherever it can produce higher levels of health and safety, and thoroughly investigate all

firefighter fatalities, injuries and near misses. (USFA & NFFF, 2004)

Developing HFACS 8

The National Fire Service Research Agenda Symposium (2005) a follow up from the

2004 Life Safety Summit identified that 100 firefighters were being killed annually with an

additional 100,000 injured in the line of duty. In an attempt to reduce injuries and fatalities, the

USFA adopted a goal of reducing fatalities by 25% in 5 years and 50% in 10 years. The

symposium was based on one of the 16 life safety initiatives which called for the development of

a national research agenda to support the implementation of advances in firefighter health and

safety. Identification of projects was made in the symposium on what efforts are currently being

made and which areas need attention on a priority basis regarding the life safety initiatives. Three

areas relative to accident analysis investigation were identified as having the highest priority

with the most critical urgency. The symposium classified each issue by identifying the need,

background and comments from participants which are listed below:

1. Issue: Analysis of Fire Service Culture

Need: Identify attitudes, beliefs and behaviors that contribute to high-risk behaviors

and resistance to changes that would improve health and safety. Also identify

effective motivators to promote positive changes.

Background: The current fire service culture is widely recognized as a barrier to

making important improvements in firefighter safety and health. Cultural values often

place bravado and heroism ahead of firefighter safety.

2. Issue: Identify Fire Ground Factors that Contribute to Fire Service Injuries and

Fatalities.

Need: The first phase of this project would be directed toward systematically

identifying and analyzing the factors that contribute to firefighter injuries and

fatalities. This would involve detailed analysis of individual cases that result in

Developing HFACS 9

injuries or fatalities, as well as “close call” situations. This would also include

statistical analysis of associated data at the local, regional, national and international

levels. The second phase of the project would be directed toward developing

mitigation strategies to address the critical risk factors and reduce injury and fatality

rates.

Background: The rate of firefighter injuries and fatalities occurring on the fire ground

is a critical concern. The research component of this effort would be directed toward

identifying critical factors that result in firefighter deaths and injuries. After these

factors are identified, effective mitigation efforts such as training programs can be

developed to address them.

3. Issue: Situational Awareness of Firefighter Physiological and Environmental

Conditions

Need: The ability to continuously monitor the location and physiological status of

firefighters who are working in hazardous areas is a critical life safety issue. The

ability to monitor external conditions within the firefighters’ work environment is

equally important, in order to identify imminent threats and changing conditions. The

information should be available to the firefighter and should also be transmitted to an

external command post, where it can be monitored and recorded.

Background: Each year, over a period of 15 years, an average of 11 firefighters had

died from asphyxiation or burns while performing interior structural firefighting

operations. Many of these fatalities occur in scenarios that involve factors of

disorientation, physical exhaustion, running out of air, and/or being overcome by

rapidly changing conditions while operating in a dangerous environment. The desired

Developing HFACS 10

solution would make the firefighter aware of dangerous situations and transmit the

data in real time so that it could be monitored and recorded outside the hazardous area.

4. Issue: Firefighter Fatalities and Injuries Involving Motor Vehicle Accidents

Need: Conduct a detailed analysis of firefighter fatalities and injuries resulting from

motor vehicle accidents in order to identify causal and contributing factors. The

analysis should include, but not be limited to: fire department vehicles, privately

owned vehicles responding to emergency incidents, vehicle age and design,

applicable design standards, vehicle inspection records, compliance with traffic laws

and response procedures, time of day and weather conditions, road surface, seat belt

usage, mechanism of injury, driver training and certification, and cause of accident.

Background: Detailed information on emergency vehicle accidents is often collected

for individual incidents; however it is not compiled or analyzed nationally. This

project would involve an effort to obtain and conduct extensive analysis of

emergency vehicle accident data (NFFF, 2005).

The United States Fire Administration (USFA) produced Fire-Related Firefighter Injuries

in 2004 (2008) which identified trends of fire ground injuries based primarily on the analysis of

the National Fire Incident Reporting System (NFIRS) fire incident data for 2004. From 1995

through 2004 firefighters injuries at fires have been double that of civilian injuries and accounted

for half of all firefighter injuries. Total firefighter injuries and fire ground injuries have

decreased throughout the 10 year period following the downward trend of fires. The percentage

of firefighter injuries per thousand fires from 1995 to 2004 has seen no noticeable decrease for

the ten years. This was an average of 24 injuries for every thousand fires (USFA 2008).

Developing HFACS 11

Literature Review

The United States Fire Administration (USFA) 2008 report Fire-Related Firefighter

Injuries in 2004, identified that incidents producing injury yielded single injuries most of the

time (82%) and just over half of the time (52%) did not result in lost work. The highest risk for

firefighter injury exists from age 20 to 39 with the leading cause of injuries relating to smoke

inhalation and exhaustion. Firefighters in the age group of 40 and above had a leading cause of

injuries relating to strains and sprains. The greatest cause of injury resulted in overexertion and

strains (16.4%) followed by exposure to fire and smoke (15.8%). More firefighters were injured

(38.4%) outside the structure than inside the structure (35%).

The general factors contributing to injuries were classified as:

Fire development 16.0%

Slippery or uneven surfaces 12.8%

Collapse or falling object 7.8%

Holes 1.8%

Vehicle or apparatus issue 1.7%

Lost, caught, trapped, or confined 1.4%

Hostile acts 0.5%

No Factor 13.4%

Other 12.0%

Unknown 32.8%

Developing HFACS 12

Physical condition prior to the highest severity injuries included:

Rested 72.4%

Fatigued 9.2%

Ill or injured 2.1%

Physical Condition 1.0%

Unspecified 15.4%

The type of activity which was being conducted at the time of injury of firefighters was

highest while extinguishing the fire or neutralizing the incident (41.0%) followed by suppression

support (20.2%). The contrast between firefighter fatalities and injuries is sharp with 79% of

fatalities resulting from heart attacks and internal trauma. Strains, wounds, and burns lead

injuries at 44% and heart attacks and internal trauma only account for 2% of injuries (USFA,

2008)

The National Institute of Standards and Technology (NIST) (2003) developed a study,

Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002. The study was developed

utilizing data obtained from National Institute for Occupational Safety and Health (NIOSH), the

National Fire Protection Association (NFPA), and the USFA National Fallen Firefighter

Memorial Database. From 1979-2002 firefighter fatalities from structural collapse accounted for

over 180 deaths not including the 2001 World Trade Center Incident. Just over half (63%) of the

deaths caused by structural collapse occurred from 1994 to 2002 for a total of 47 incidents. This

included eight of the last twenty-three years studied. Almost half of the deaths involved career

firefighters with six or more years of experience. The nature of deaths identified in structural

collapse included; asphyxiation, burns, internal trauma and other causes. Asphyxiation accounted

for 42% of the fatalities. In two previous NFPA studies 60% of the fatalities come from being

Developing HFACS 13

caught or trapped; 40% of the fatalities were struck or had contact with an object. From 1994 to

2002 the percentage rose to over 85% being caught or trapped. The report concludes that the

number of fatalities due to collapse has declined since 1979; however, the number of collapse

fatalities in residential structures has increased drastically. Collapse fatalities occur by

firefighters being caught or trapped in the structure or being struck by an object, and the study

has shown that the percentage of being caught or trapped has increased. The probable causes for

the trends were not determined due to the need for additional data. (NIST, 2003)

The International Association of Firefighters sponsored a research project by Moore-

Merrell, Zhou, McDonald-Valentine, Goldstein, and Slocum (2008) Contributing Factors to

Firefighter Line-Of-Duty Injury in Metropolitan Fire Departments in the United States

evaluating nine metropolitan fire departments. The group evaluated 3450 injuries with

dominating contributing factors leading to lack of situational awareness at 37.35%, lack of

wellness or fitness at 28.57% and human error at 10.65%. The premise of the research was based

on classifying the injuries into contributing factor clusters or contributing factors which occurred

together.

The first cluster included equipment failure, lack of training, structural failure, act of

violence, civilian error, horseplay and lack of teamwork. The second cluster included crew size,

lack of wellness or fitness, fatigue, and weather or act of nature. The third cluster included

protective equipment not worn and dangerous substance. The fourth and final cluster included

decision making, lack of communication, standard operating guideline or procedure breech,

protocol breech, human error, and lack of situational awareness. The fourth cluster was identified

as being responsible for more than 30% of all firefighter injuries while the second cluster was

Developing HFACS 14

responsible for 26.2% of the injuries over the two year period of 2005-2006 (Moore-Merrell, et

al, 2008).

With the broad classification of causal factors the clusters identified decision making,

lack of communication, standard operating guideline or procedure breech, protocol breech,

human error, lack of situational awareness, crew size, lack of wellness or fitness, fatigue, and

weather or act of nature as being responsible for 56.2% of the injuries. The second and fourth

clusters carried the highest percentage in all categories including age, years of service, scene type,

and type of duty. In the final discussion, Moore-Merrell et al. identified that the association

between factors within a cluster could not be identified and that they may act independently or

collectively (Moore-Merrell, et al, 2008)

The United States Naval Safety Center (NSC) (2006) produced The Navel Flight

Surgeon’s Pocket Reference to Aircraft Mishap Investigation Sixth Edition, which provides a

comprehensive standard for investigating naval aircraft incidents. As stated in the reference,

HFACS provides a proven template to aid the investigator in organizing the incident while

providing a detailed analysis of human error. Historical data provided that human error with

other factors or alone is present in approximately 80% of the aircraft mishaps. Causal factors are

defined as the factors which resulted in the incident occurring causing unnecessary injury or

damage. Most aircraft mishaps are the result of a combination of two or more causal factors, in

which one factor removed, would prevent the mishap from occurring. All causal factors are

considered to be “under human control”; therefore, all hazards can be eliminated and mishaps

prevented. Environmental conditions (weather) are not hazards, as the choice to perform in the

condition would be the hazard.

Developing HFACS 15

Mishaps for the NSC aircraft incidents are classified by severity with Class A through C

requiring an investigation:

1. Class A

Aircraft destroyed or missing, or

Property damage of $1,000,000 or greater, or

Fatality or permanent disability as a result of the mishap

2. Class B

Property damage between $200,000 to $1,000,000, or

Permanent or partial disability as a result of the mishap, or

Hospitalization of three or more personnel

3. Class C

Property damage of $20,000 to $200,000, or

An injury that results in 5 or more lost workdays

4. Hazard

Property damage of less than $20,000, and

There are no reportable injuries

The event is not a mishap it would be reported as a hazard

The NSC reference manual also includes a Risk Assessment Codes (RAC) matrix used to

identify severity and probability of the mishap reoccurring in the future. In the matrix hazard

severity is classified in Arabic numbers to determine hazard abatement priorities, as mishap

probability is identified as Alphabetic letters identified below:

Developing HFACS 16

Hazard Severity Category:

I. The hazard may cause death or loss of a facility or asset (Class A Damage).

II. May cause severe injury, severe occupational illness, significant property damage,

or severe degradation to assets (Class B Damage).

III. May cause minor injury, minor occupational illness, minor property damage, or

minor degradation to assets (Class C Damage).

IV. Would not significantly affect personnel safety or health, property or asset;

however, it is a violation of an established regulation or standard.

Mishap Probability:

A. Likely to occur immediately or in a short period of time (one or more times in the

next year).

B. Likely to occur in time (within the next 3 years).

C. Likely to occur several times during the life of the aircraft.

D. Unlikely to occur, but is feasible within the lifetime of the aircraft.

Mishap Probability Hazard

Severity A B C D

I 1 1 2 3

II 1 2 3 4

III 2 3 4 5

IV 3 4 5 5

Developing HFACS 17

RAC Definitions:

1. Critical Risk

2. Serious Risk

3. Moderate Risk

4. Minor Risk

5. Negligible Risk

The NSC reference identifies that human error has been identified in many arenas as the

cause of the accident occurring; however, stopping at human error is a naïve approach to mishap

causation. The goal of a mishap investigation is to identify and determine why the failures or

conditions led to the mishap and how it can be prevented in the future. Mishaps are rarely

attributed to a single cause or even a single individual. Mishaps are the result of a myriad of

latent and active failures. The reference defines active and latent failures by sighting James

Reason (1990) who developed the concept of human error with active and latent failures

inspiring Wiegmann and Shappell to develop HFACS. Active failures are the actions or inactions

of people who are believed to have cased the mishap. Latent failures are the errors that exist

within a crew, organization, supervision or preconditions which may have been previously

dormant. Reason’s (1990) Swiss Cheese model is also identified in the reference which provides

a simplistic depiction identifying that each failure is like a slice of Swiss cheese (defense barriers)

which has holes in it (failed or absent defenses) and as the holes align a mishap occurs. The

model has four levels (slices of cheese) as identified below:

Developing HFACS 18

1. Unsafe Acts – Active Failures

2. Preconditions for Unsafe Acts – Latent Failures or Conditions

3. Unsafe Supervision – Latent Failures or Conditions

4. Organizational Influences – Latent Failures or Conditions

(Appendix A)

Most investigations as stated in the reference stop at the unsafe acts level which identifies

the human involved in the error or the surface of the problem instead of identifying the latent

failures influencing the mishap. Without identification of the latent failures proper measures can

not be taken to prevent future incidents (NSC, 2006).

The “Swiss Cheese” model created by James Reason (1990) was developed to help

concept that as human error is the cause of most incidents the root cause usually lies deeper in

the organization. Douglas Wiegman and Scott Shappell (2003) built upon the model of Reason to

develop categories of each area of unsafe acts, preconditions, unsafe supervision, and

organizational influences. Wiegman and Shappell gained their experience at the NSC as human

factor psychologist, flight surgeon and Navy Commander. Unsafe acts are divided into two areas,

errors and violations. Errors are frequently the first to be identified since human beings by their

Developing HFACS 19

very nature make errors. As stated by Wiegmann and Shappell (2003) To err is human (Plutarch

100 AD). Violations are not as frequently recognized as they represent the willful disregard for

the rules.

Errors are broken down into three additional areas including; skill based errors, decision

errors, and perceptual errors. Skill based errors are those which are based on basic skills which

occur without significant thought. With skill based errors relying on attention and/or memory-

they are very vulnerable to failures. Some of the skill based errors which are associated with

attention failures include breakdown in visual scan patterns, task fixation, and miss-ordering

procedural steps. Memory failures being different than attention failures, include items such as

omitted checklist, losing place, or forgotten intentions. Skill based errors can also happen even

when no apparent attention of memory failure is present. Decision errors are the intentional

behaviors which are inappropriate or inadequate for the situation, often referred to as honest

mistakes. Perceptual errors exist when the individual’s perception of the world is different than

reality or when sensory inputs are disregarded which may be classified as visual illusions or

spatial disorientation (NSC, 2001).

Violations are separated by routine and exceptional violations. Routine violations are the

willful departure from authority that simply cannot be tolerated which tends to be routine or

habitual by nature or part of the individuals normal behavior. Exceptional violations are those

which appear as isolated departures from authority which are not necessarily part of the

individual’s behavior or condoned by management (NSC, 2006).

Developing HFACS 20

Unsafe acts provides the information on the individual performance which caused the

incident to occur which can also provide information on what caused the incident the majority of

the time. However, only identifying the unsafe acts is focusing on a symptom without identifying

the cause. The first form of identifying the deeper cause beyond the unsafe acts is to identify

preconditions to unsafe acts. The preconditions of unsafe acts are divided into two primary areas-

including; substandard conditions of operators, and substandard practices of operators (NSC,

2006)

Substandard conditions of operators are further subdivided into three additional

conditions - adverse mental states, adverse physiological states, and physical/mental limitations.

An adverse mental state takes into account those conditions which affect performance and the

individual’s mental preparedness for the task. Adverse physiological states include conditions

that preclude to the incident such as physical fatigue, hypoxia, or pharmacological and medical

treatments or conditions. Physical/mental limitations are identified as the task exceeding the

capabilities of the individual’s physical or mental abilities (NSC, 2001).

Developing HFACS 21

Substandard practices of operators are subdivided into crew resource management and

personal readiness. Crew resource management is the proper coordination of the crew during

operations also including communications within and outside the crew. Personal readiness

identifies individual’s expectations and performance levels such as physical and mental

preparedness for the task. One item of consideration stated in the NSC Resource is that

preconditions such as personal readiness may not be standard practices, however does not violate

or relate to regulations (NSC, 2001).

Unsafe supervision is the third process which contains four primary categories. The four

supervisory categories are inadequate supervision, planned inappropriate operations, failed to

correct a known problem, and supervisory violations. Inadequate supervision contains the basic

principles of the supervisor providing the crew the opportunity to succeed through guidance,

training, leadership, motivation, and the proper role model. Planned inappropriate operations

identifies crews being placed in unacceptable risk adversely affecting performance in such ways

as improper pairing of crew members with minimal experience. Failing to correct a known

problem arises when known deficiencies among individuals, equipment, or training, as well as

inappropriate behaviors, unsafe atmospheres, or other unsafe areas continue to exist without

Developing HFACS 22

being corrected. Supervisory violations happen when there is willful disregard for the rules or

procedures, such as allowing an individual to perform a function without proper or sufficient

qualifications (NSC, 2001).

Organizational Influence is the final level identifying fallible decisions of upper-level

management which filters down through the organization. The three categories of organizational

influences include resource management, organizational climate, and operational processes.

Resource management refers to the management, allocation, and maintenance of organizational

resources including human, monetary, equipment, and facilities. Organizational climate refers to

the treatment of individuals and the climate of the organization. Organizational climate is broken

down into three further categories including structure, policies, and culture. Organizational

process is the formal process by which things are done in the organization. The organizational

processes can be further divided into three categories of operations, procedures, and oversight

(NSC, 2001).

Developing HFACS 23

The Federal Aviation Administration (FAA) published a document Human Error and

General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS in 2005.

The HFACS’s original framework was developed for the U.S. Navy and Marine Corps as an

accident investigation and data analysis tool for aviation incidents. Since its creation other

agencies have utilized the program including the FAA as a complimentary program. HFACS has

been cited by the Aeronautical Decision Making Joint Safety Analysis Team as a useful tool in

identifying the human error component of aviation accidents.

In the FAA document a set of research questions were developed to analyze the benefits

of the HFACS systems. The research revealed that most incidents were associated with multiple

causal factors. The data indicated skill based errors were associated with the largest percentage

of the accidents and the most fatalities (79.2%) followed by decision errors (29.7%), violations

(13.7%), and perceptual errors (5.7%). Violations performed by the operator increased the

chances of a fatal incident by 4 times. With the high number of skill based errors the cause was

identified as being most susceptible to distractions during low processing task, lower levels of

experience, and training. Reason (1990) defined skill based errors as those which occur during

the execution of routine events. Reducing skill based errors is identified as utilizing increased

Developing HFACS 24

experience and training, detailed checklist, increased automation of critical task, workload

management, and training. The conclusion of the report identifies that existing prevention

programs are not effective as they focus on the specific types of accident rather than specific

types of human error. Focusing on types of accidents provides interventions which are narrow in

scope producing change in aircraft, existing policies, or regulations (FAA, 2005).

The United States Department of Defense (DOD) (2005) Human Factor Analysis and

Classification System provides a mishap investigation and data analysis tool. The history

reported in the document provides statements from the Secretary of Defense in a memorandum

published on May 19, 2003. The Secretary stated “World-class organizations do not tolerate

preventable accidents. Our accident rates have increased recently, and we need to turn this

situation around. I challenge all of you to reduce the number of mishaps and accident rates by at

least 50% in the next two years”. The statement and ensuing memorandum resulted in the DOD

Safety Oversight Committee to provide guidance in accomplishing the directive. The committee

was charged with reviewing accident trends, advise on improvements, develop and implement

safety initiatives, and coordinate with other agencies to facilitate research, standards,

performance, education, and equipment. The evaluation of the safety oversight committee led to

the use of HFACS in all mishaps (DOD, 2005).

In an article from Jennings (2008) Human Factors Analysis & Classification applying the

Department Of Defense System During Combat Operations in Iraq identifies how the HFACS

system was adapted for combat. The taxonomy of the original HFACS remained constant with

unsafe acts, unsafe supervision, and organizational influences; however, preconditions for unsafe

acts changed considerably. The division of preconditions to unsafe acts is broken down into

environmental factors, condition of individuals, and personnel factors. Environmental factors

Developing HFACS 25

include two sub categories of physical environment and technological environment. Condition of

individuals was broken down into cognitive factors, psycho-behavioral factors, adverse

physiological states, physical/mental limitations, and perceptual factors. Personnel factors were

separated by coordination/communication/planning factors and self imposed stress (Jennings,

2008).

The other areas of difference are found in the causal factors. An example is made

utilizing a rollover incident analysis of a motor vehicle crash, which was plaguing the combat

arena. The article which identifies each of the divisions, categories, subcategories, and causal

factors relating to the crash was identified as follows:

Developing HFACS 26

Division Category Causal Factors Unsafe Acts Skill Based Errors Overcontrol/Undercontrol Unsafe Acts Violations Lack of Discipline Preconditions Condition of Individual Fatigue-Physiological/Mental Unsafe Supervision Inadequate Supervision Oversight Inadequate

Unsafe Supervision Planned Inappropriate Operations Limited Total Experience

Unsafe Supervision Planned Inappropriate Operations Risk Assessment-Formal

Organizational Influences Organizational Climate Unit Organizational Values/Culture Organizational Influences Organizational Climate Unit Vehicle/Equipment Change Organizational Influences Organizational Process Organizational Training

Without full information of the incident, total comprehension is not gained; however, the

HFACS analysis does provide an example of the program and depth of causal factors and

behaviors beyond the operator. Jennings also states that the DOD-HFACS is an effective tool

that can be used to identify and mitigate hazards, management issues, and accidental loss to

improve the combat environment. The DOD-HFACS system is attributed to identifying and

providing mitigation programs which provided a 62% decrease in rollovers and a 75% decrease

in fatal rollovers during a three year period. The rollover prevention program provided a primary

focus on management due to the DOD-HFACS evaluation of the events (Jennings 2008).

The Australian Transport Safety Bureau (ATSB) (2007) published a document Human

Factor Analysis of Australian Aviation Accidents and Comparison with the United States. The

document identifies the benefit to aviation safety by increasing knowledge of human factors

includes the ability to identify safety problems, to design evidence-based interventions that

reduce error frequency, to learn from solutions of others, and to provide opportunities for others

to learn from initiatives. Validation of HFACS in the document identifies successful use in

aviation, road, rail transportation, medical, oil and mining industries. The HFACS program is

Developing HFACS 27

also utilized by military and civilian organizations in the United States, Canada, United Kingdom,

India, Israel, Greece, and the Netherlands. With the increasing variety of industry and

international use, HFACS is established as a reliable and valid accident classification tool. The

international evaluation by Australian Transport Safety Bureau reaffirmed there were differences

in contributory factors between the countries. Skill based errors still held the highest number of

causal factors followed by decision errors, violations, and perceptual errors (ATSB, 2007).

Human Error Investigation Software Tool (HEIST) developed by the Department of

Transportation (DOT) for the Federal Railroad Administration (FRA) in 2007 states that human

factors are a leading cause of train accidents and incidents in the United States. The document

identifies that human factors go beyond crewmembers on the track and include management

support and oversight, procedures, technology, facilities, and culture. In 2004 DOT initiated the

development of systematically structured software to provide accident analysis on human factors

(DOT, 2007).

With the development of the software, the following tasks were set to be examined; to

identify an appropriate human factors framework, to document the practice in accident

investigations, develop a set of user requirements, and to produce an initial concept of operations.

HEIST was based on Reason’s (1990) accident causation theory and structured around a

validated human factors classification system HFACS developed by Wiegmann & Shappell

(2003). The HEIST program as modified from the original HFACS program provides changes in

operator acts (unsafe acts), preconditions for operator acts, and organizational factors with no

change in supervisory factors, and an additional category of outside factors. Operator acts

(unsafe acts) are separated into errors and violations as in the original HFACS. Violations are

broken down into routine and exceptional with the addition of acts of sabotage. Errors are broken

Developing HFACS 28

down into skill based errors, decision errors, and perceptual errors. Unlike the original HFACS

skill based errors and decision errors are broken down further. Skill based errors subcategories

include attention failure, memory failure and technique error. Decision errors subcategories

include procedural error, poor choice and problem solving (DOT, 2007).

Preconditions for operator acts were changed mostly in the wording of condition of

operators, personnel factors, and the additional category of environmental factors. Environmental

factors are subdivided into physical environment and technological environment. Condition of

operators is subdivided into adverse mental states, adverse physiological states, and

physical/mental limitations. Personnel factors are subdivided into crew resource management

and personal readiness (DOT, 2007)

Developing HFACS 29

Supervisory factors remained relatively unchanged from the original HFACS taxonomy

being divided into inadequate supervision, planned inappropriate operations, failure to correct

problem, and supervisory contraventions (violations) (DOT, 2007).

Organizational factors were changed from the original HFACS taxonomy by the addition

of subcategories under resource management, organizational climate, and organizational process,

and the addition of change management. Resource management was subdivided into human

resources, equipment facility resources, and monetary budget resources. Organizational climate

was subdivided into organizational structure, organizational policies, and organizational culture.

Organizational process was subdivided into organizational operations, organizational practices

and procedures, and organizational (safety) oversight (DOT, 2007).

Developing HFACS 30

The new field which was added was outside factors which were subdivided into

regulatory oversight and economic/political/social/legal environment (DOT, 2007).

A unique approach to the use of the human factor analysis was identified in A System

Perspective on Road User Error in Australia: Swiss cheese and the road transport system by

Salmon, Reagan and Johnston (2008). Salmon, et al, cites research which identified driver error

contributing to 75% of roadway crashes. Despite the identification of error related crashes

causing the major problem, further research has been limited. The document identified research

toward a framework for an error tolerant road transportation system. The theory provided an

outlook of increasing tolerance of errors instead of eradicating errors. The theory was based on

Developing HFACS 31

the fact that drivers will always commit errors, which will never completely be avoided.

However, understanding and preparing for errors will decrease the severity (Salmon, et al, 2008).

A taxonomy was created to better identify errors and causal factors contributing to the

errors. The taxonomy was divided into five primary categories including; road infrastructure,

vehicle, road user, other road users, and environmental conditions. Road infrastructure is further

classified by road layout, road furniture, road maintenance, and road traffic, rules, policy and

legislation. Vehicle is broken down into human machine interface, mechanical, maintenance, and

inappropriate use of technology. Road user subcategories are physiological state, mental state,

training, experience, context related, non-compliance and knowledge, skills and abilities. Other

road users are other driver behavior, passenger effects, pedestrian behavior, bicyclist behavior,

law enforcement, and other road user behavior. Environment conditions consist of weather,

lighting, time of day, and road surface conditions (Salmon, et al, 2008).

With these areas identified the information is then further classified into whether the

errors are classified as a slip, lapse, mistake or violation to complete the evaluation. The error

taxonomy which was classified to evaluate roadway crashes was based on the principles of

identifying the engineering, enforcement, and education needs in preventing or tolerating errors

causing crashes (Salmon, et al, 2008).

The Field Guide to Understanding Human Error was originally developed in 2002 and

revised in 2006 by Sidney Dekker (2006) of Land University in Sweden primarily outlining

investigation theory. Dekker (2006) identifies two outlooks on identifying errors. The first

outlook is when an investigation stops after identifying the cause of the mishap or human error,

also referred to as “The Old View” by Dekker. The second identifies the human error as a

symptom of deeper trouble found in the tools, tasks, operations, organization, and environment

Developing HFACS 32

also referred to as “The New View” by Dekker. An entire chapter of the book is dedicated to

hindsight bias because all investigations are evaluating incidents with hindsight. A reaction to

failure creates bias in many instances while reviewing past events reverting to “The Old View”.

Dekker (2006) outlines the problem with reacting to failure as interfering with understanding the

total problem. He implies the more reaction to failure the less the cause is understood. In

evaluating an incident if the evaluator focuses on their knowledge of the incident or hindsight

bias instead of why the individuals made the decisions the extent of the cause will not be

determined. Hindsight causes an outlook that a sequence of events inevitably lead to an outcome,

a sequence of events is linear without interruptions and causality is oversimplified (Dekker,

2006).

Dekker (2006) outlines one of the primary keys in evaluating human error is

understanding human behavior by looking at the incident as the individuals involved participated

in the incident, “put yourself in their shoes” to understand why they made the decisions when

they made them. In evaluating the decisions the individuals made when they made them with the

factors present, it may be identified that the right decision was made at the time, unlike

evaluating with hindsight bias where the decisions are assumed incorrect due to the cause of

failure.

Dekker (2006) utilizes the analogy of the sharp and blunt end of the accident with the

sharp end being the failure caused by the operator and the blunt end being the organizational

factors leading up to the cause. The sharp end identifies active failures (the act), while the blunt

end identifies latent failures (preconditions, supervision, and organizational issues). To identify

issues with organizational problems or deficient safety culture, Dekker outlines resilient

organizational qualities or a strong safety culture.

Developing HFACS 33

Resilient organizations include management commitment having a high priority in safety,

and involvement understanding the operational safety and risk. Resilience also identifies

employee empowerment where the employees feel they can make a difference by influencing

policies and taking pride in safety; incentive structures connected to safety behaviors; and

reporting systems providing reporting, learning, and improvements in safety. A safety culture is

identified as a system that allows the boss to hear bad news, which provides an environment for

the employees to feel comfortable in delivering bad news knowing management will act upon it

with out repercussions. An example of delivering, evaluating, and disseminating information is

through the work of physicians in the morbidity and mortality conference where errors causing

damage or death are communicated to provide causal understanding and prevention (Dekker,

2006).

Managing The Unexpected by Weick and Sutcliffe (2007) is based on developing and

maintaining high reliability organizations (HRO). Organizations classified as high reliability

organizations are those which require high performance where the potential for error is

overwhelming such as air traffic control, aircraft carriers, hostage negotiators, nuclear power

plants, and firefighters. High reliability organizations provides a mindful infrastructure that

continually tracks small failures, resist oversimplification, remains sensitive to operations,

maintains capabilities for resilience, and takes advantage of shifting locations of expertise.

Failure within an HRO is classified as having a much greater potential for being catastrophic

than within non HRO organizations due to the nature and environment of the work (Weick &

Stancliffe, 2007).

Weick and Stancliffe (2007) define preoccupation with failure as an HRO’s ability to

treat any lapse as a symptom of the system or something which individually or combined with

Developing HFACS 34

another lapse can have sever consequences. An HRO will address all incidents which occur to

determine cause and effect in order to prevent future incidents. Reluctance to simplify could also

be identified as being non complacent. An HRO being in a complex, unstable, and unpredictable

environment while experiencing oversimplification or complacency could lead to failures.

Sensitivity to operations is being attentive to the front line where the work gets done. HRO’s are

less strategic and more situational. With well developed situational awareness, adjustments to

prevent errors are continuous. Commitment to resilience allows an organization to maintain

stability and continuous operations after a major mishap or under continuous stress. Resilience

keeps errors small and maintains workarounds demanding knowledge of technology, the system,

coworkers and oneself (Weick & Stancliffe, 2007).

An HRO places priority on training, personnel with varied experience and skills, and

making do with what they have to take worst case scenarios and drill out solutions. Deference to

expertise is developed through HRO’s who cultivate diversity in personnel who may have a wide

array of knowledge and experience. With deference to expertise the decision making is not

terminated by rank, instead it is pushed down to others on the front line with the most expertise

not necessarily rank. Information outlining HRO provides examples of failure prevention and

positive behaviors such as situational awareness, crew resource management, and many other

examples which are outlined in the human factor analysis classification system (Weick &

Stancliffe, 2007).

Gary Klein (1998) identified how people make decisions in Sources of Power where he

provides extensive studies on different groups of people and the methods for their decisions. One

of Klien’s primary study groups was firefighters where he outlines the recognition-primed

decision model (RPD). To understand recognition-primed decisions Klien first defines a decision

Developing HFACS 35

as actively comparing two or more options in a process of comparative evaluation. The

recognition-primed decision model developed when the findings resulted in decisions being

made without comparing options. In the studies of the firefighter’s decisions, it was found that

decisions were based off of experience instead of comparison. The decisions based on experience

proved to be reasonable, rapid decisions, except when the individual had not experienced the

environment (Klein, 1998).

The decisions made were classified as singular evaluation strategy which would

determine the course of events unless the choice did not work where other considerations would

be made working toward a comparative evaluation strategy. The recognition-primed decision can

be defined as recognizing the situation as familiar (relating to previous incidents) and

recognizing a course of action likely to succeed. Recognizing the situation may also be combined

with evaluating the course of action with the individual imagining how the incident will play out.

The one step that is left out from the comparative evaluation is diagnosing the situation which

may be done if the course of action is not successful or as a follow up to ensure continuing the

chosen course. The best explanation of recognition-primed decision was made using the analogy

of a slide show. Every individual’s experiences are stored in a slide show (previous incidents)

and when a new incident occurs the individual chooses a slide (previous experience) which most

closely matches the incident at hand and makes the decisions based on the chosen slide (Klien,

1998).

Klien (2003) further investigates recognition-primed decision making in The

Power of Intuition. Again evaluating firefighters and military personnel Klien carries the quick

decision making process a step further identifying intuitive decision making. Similar to

recognition-primed decision making, intuitive decision making is defined by Klien as the way we

Developing HFACS 36

translate our experience into action. As Klien identified intuition in Sources of Power he

exemplified it in The Power of Intuition with his initial work based primarily on firefighter’s

decision making process (Klien, 2003).

Klien (1998) identifies why good people make poor decisions, as poor decisions

are not necessarily made, as much as they are created by poor information, environments,

knowledge, and experience. Klien also found that stress does not create poor decisions; however

it distracts attention, prevents using working memory, and keeps the individual from gathering

further information. Poor decisions would be better classified as poor outcomes based on the fact

that the individual made the decision based on the information and expertise at the time of the

incident. Klien provides the best defense for poor outcomes is expertise which allows the

decision maker to act rapidly with certainty (Klien, 1998).

Uncertainty creates doubts also known as risks, probabilities, confidence, ambiguity,

inconsistency, instability, confusion, and complexity resulting in poor outcomes. Uncertainty

exists when information is missing, unreliable, conflicting or complex. One example of

uncertainty is when the individual explains away all of the indicators of a problem. Many times

indicators of problems exist which individually do not indicate concern; however, collectively

indicate a primary identifier. Uncertainty is also classified in levels directly related to the level of

knowledge, data, and understanding (Klien, 1998).

Procedures

The procedures for the research of this project began with an extensive literature review

consisting of periodicals, text books, manuals, and previous research. The identification of the

selected literature was derived from the National Fire Academy Learning Resource Center,

Developing HFACS 37

internet web searches, and from professionals in the HFACS field. The review provided an

extensive knowledge of the understanding and development of HFACS in multiple industries.

To begin to evaluate the development of the use of HFACS in the fire service the

National Fire Fighter Near-Miss Reporting System provided assistance with data obtained from

the near-miss reporting since its inception. The Near-Miss data provided some information

regarding causal factors as it collected data from selective causal factors in HFACS. Evaluation

of the data was performed to determine causal factors previously identified in the fire service.

The next step included combining all of the categories, subcategories, and causal factors

which were being utilized by the industries identified in the literature review. The merger of the

systems created overlaps of categories, subcategories, and an abundance amount of causal factors.

To provide the first step in the evaluation process, the current and previous Executive

Fire Officers in North Carolina was requested to assist with evaluating the merged systems. The

participants were requested to meet at the North Carolina Office of State Fire Marshal to achieve

two objectives including evaluate the combined systems to determine the relation to the fire

service and to utilize the system in firefighter fatality reports to ensure the categories,

subcategories, and causal factors effectively capture the needed data for the fire service. Prior to

the evaluation date all of the evaluators were sent the article Human Factor Analysis

Classification Applying the Department of Defense Program to Combat Operations in Iraq by

Jennings (2008) to provide as a primer. This process narrowed down the system utilizing

portions of all three industry systems.

The second step of the evaluation program was to evaluate the categories, subcategories

and causal factors which had been determined by the initial evaluation. The information was then

put into a spread sheet with descriptions of each factor, and evaluator input for each causal factor

Developing HFACS 38

in three areas including; need, probability and priority. The need was available for the evaluator

to determine whether the causal factor was needed by an indication of yes or no. Probability had

four options for the evaluator to select - frequent, often, rarely, and never. Priority had three

selections of high, medium and low. Upon completion the evaluators returned the spreadsheet

with their selections which allowed for compilation and evaluation of the responses. Based on

need, probability, and priority the causal factors were further narrowed to ensure the highest

priority and most probable factors were utilized with the least number of factors.

The final procedure was to develop a flow chart to illustrate the categories, subcategories,

and causal factors or codes. The flow chart was established based on Shapell & Wiegman’s

(2003) illustration of a taxonomic framework. The flow chart provides a greater understanding of

the system identifying the proceeding from category to category.

The primary limitation of the procedures was the number and variety of evaluators. The

current and previous EFO students in North Carolina number 18 from a wide variety of

organization types; however, the number participating in the primary and secondary evaluation

was limited. The second limitation was the amount of education and training on HFACS prior to

the work by the evaluators. Complete evaluation of the HFACS tool is also limited by the

number and types of incidents available. The final and most extensive limitation is the amount of

data on specific causes of incidents and injuries in the fire service.

Results

The path to develop HFACS has been extensive in identifying the necessary information

in order to code it for the fire service. With little cross reference for the fire service, the

development required utilizing other industry tools and evaluating the results for the fire service.

Developing HFACS 39

The one tool in the fire service, which is utilizing a hybrid HFACS is the National Fire Fighter

Near-Miss Reporting System developed by the International Association of Fire Chiefs. By

utilizing the Near-Miss database some of the categories and causal factors were identified. The

database consists of 1817 events starting since 2005. The top five incidents that were identified

in 1,429 reports in the data base included:

Type of Incident Percent

Fire Emergency (Structure, Wild land, Vehicle) 43.02%

Vehicle Event (Responding to or from) 26.40%

Training Activity 10.12%

Non Fire Emergency (Rescue, Extrication, EMS, Service) 6.63%

On Duty Activity (Apparatus Check, etc.) 5.20%

Other 18.75%

Utilizing the HFACS model in 447 reports of the Near Miss program the following identification

of the divisions was found:

HFACS Division Percent

Unsafe Acts 47.87%

Preconditions to Unsafe Acts 31.32%

Unsafe Supervision 11.41%

Organizational Influences 8.28%

Developing HFACS 40

In the Near Miss program the reporting individual has the ability to report multiple contributing

factors. The following information is developed from an average of two factors in 1,242

incidents. In the reporting system, definitions of the contributing factors are not listed on the web

site so when report submitters select the contributing factors, it is unknown what their knowledge

or perceptions of the definitions are.

Contributing Factor Percent

Decision 17.92%

Human Error 16.7%

Situational Awareness 13.25%

Other 11.97%

Individual Action 8.15%

Equipment 8.1%

Communication 7.15%

Command 5.55%

Accountability 3.75%

Training Issue 2.95%

Procedure 2.85%

Weather 1.65%

Other choices for contributing factors that are not listed include; protocol, staffing, task

allocation, teamwork, unknown, SOP/SOG, horseplay, and fatigue. All of these factors had a

value of less than 1% in the database (National Firefighter Near Miss Database, 2008).

Developing HFACS 41

A focus group was established at the NCOSFM to evaluate HFACS for the fire service,

after merging the system utilized by the Naval Safety Center, Department of Defense, and

Department of Transportation where each area was evaluated on the need, probability and

priority for the fire service. The following structure was identified as the most needed with the

highest probability or priority for the fire service having divisions, categories, and subcategories

as follows:

Division Unsafe Acts Category Errors Violations

Sub Category Skill Based Routine

Decision Exceptional Perceptual

Division Preconditions to Unsafe Acts

Category Condition of Operator Personnel Factors Environmental

Factors Sub

Category Cognitive Crew Resource

Mgmt Physical

Environment Psycho-Behavioral

Factors Personnel ReadinessTechnological Environment

Adverse Physiological State Self Imposed Stress

Perceptual Factors

Coordination Communication

Planning

Division Unsafe Supervision

Category Inadequate Supervision

Planned Inappropriate Operations

Failed to Correct Known Problem

Supervisory Violation

Developing HFACS 42

Division Organizational Issues

Category Resource ManagementOrganizational

Climate Organizational

Process Human Resources Structure Operations

Monetary Resources Policies Procedures Equip/Facility

Resources Culture Oversight Acquisition Mgmt

Establishing the structure was the first step in the process, to identify behaviors. It was necessary

to establish causal factors of each subcategory. When developing the causal factors or codes it

was determined that examples would be necessary so the user could clearly make a decision. The

following information contains the causal factors and examples developed by the focus group for

each category:

Unsafe Acts Causal Factors Examples

Decisions Skill Based Errors

Breakdown in visual scan Did not see the floor was gone Poor technique Took a 1 3/4 line instead of 2 1/2 Failed to prioritize attention Did not ventilate with fire in the rafters

Developing HFACS 43

Task overload Not enough support with multiple incidents

Negative habit Driving with engine break on in adverse conditions

Failure to see and avoid Drove into a ditch

Distraction Focusing on communications instead of driving

Checklist error Did not check apparatus off Procedural error Started PPV before ventilating structure

Overcontrol / under control of situation Lost control of apparatus

Decision Errors Inappropriate maneuver/procedure Did not park apparatus to protect scene Inadequate knowledge of systems, procedures Did not know how to get foam on line Exceeded ability Attempted attack with one crew needing more Wrong response to condition Water flowed from outside on inside crew

Risk assessment-during operations Objective not changed with changing conditions

Task miss-prioritization Started attack before rescue Necessary action - rushed Responded to rapidly Necessary action - delayed Did not start water supply when needed Necessary action - ignored Needed water supply Attention failure Did not recognize collapse signs

Poor choice Chose to go in without a partner

Perceptual Errors Visual illusion Road lanes obscured by wet pavement Spatial disorientation Fog, smoke, no visibility Misjudged distance, speed, clearance Too fast for curve

Misperception Underestimated incident factors

Violations Routine

Inadequate briefing Did not pass on info about hazards Violation of orders, regulations, SOP's Did not establish a RIT Failed to inspect apparatus Did not find loose equipment Based on risk assessment Did not perform walk around Lack of self discipline Failed to use safety equipment

Exceeded weather condition Drove too fast for conditions

Exceptional Exceeded limits of apparatus Not enough stopping distance Accepted unnecessary hazard Did what they were told knowing it was unsafe Not current/qualified Did not have 1403 classes entering live burn Failed to obey general statutes Did not wear seat belt Willful disregard Did not stop for a red light

Developing HFACS 44

Preconditions to Unsafe Acts Causal Factors Examples

Condition of Individual Cognitive Factors

Inattention Did not pay attention to conditions Mental task over saturation Too many objectives for one person Confusion Did not understand orders Distraction Thinking about personal problems Geographic miss orientation (lost) Lost in the structure Loss of Situational Awareness Caught in a flashover Stress Outside events causing stress Alertness Line officer Mental fatigue Continuous information processing overload Tunnel Vision Going to the smoke instead of size up Memory lapse/failure Did not call for mayday when lost

Technical/procedural knowledge Shutting off chlorine tank without knowledge

Psycho-Behavioral Factors Emotional state Not recovered from CIS Overconfidence Inherent personal attribute Complacency Not wearing helmet strap Inadequate motivation Don’t want to be there Misplaced motivation Wanting to look good Overaggressive Taking unnecessary chances Excessive motivation to succeed Competitive nature Get-home-it is/get-there it is Just wanted to get there or go home Motivational exhaustion No longer motivated to complete objectives Information overload Too much unnecessary info

Inadequate experience Did not have enough experience

Adverse Physiological States Medical illness Come to work with flue Hypoxia Not wearing SCBA in O2 deficient Physical fatigue Worked for over 48hrs Intoxication Drinking or illegal drugs Effects of over the counter medication Taking ephedrine for weight loss Prescribed drugs Taking painkillers Operational injury/illness Sprained ankle and continued working Pre-existing physical illness, injury, or deficit Overweight Dehydration Overheated without fluids Physical Task Over saturation Overworked Visual limitations Could not see due to SCBA mask Inadequate reaction times Did not react quickly to high heat

Incompatible physical capabilities Was not physically fit

Perceptual Factors Misperception of operational condition Did not realize fire in the attack Misinterpreted/misread condition Did not read smoke

Developing HFACS 45

Auditory cues Did not hear cylinder venting

Personnel Factors Crew Resource Management

Failed to conduct adequate brief Did not inform crew of objectives Lack of teamwork Worked as individuals Lack of assertiveness Officer did not command direction Poor communication Crew did not communicate up and down Poor coordination Ventilation and attack worked against Misinterpretation of communications Did not confirm communication Lack of trust Crew did not trust decisions

Failure of leadership Leader did not lead

Personal Readiness Adequate crew rest No rehab between operations Inadequate training Crew not trained for operations Self-medicating Taking meds causing inattention Overexertion prior to duty No rest between off and on duty activity Poor dietary practices Weight loss diet causing fatigue

Pattern of poor risk judgment Continuously driving fast

Self-Imposed Stress Physical fitness Not physically fit Alcohol Drinking alcohol Drugs/supplements/self medication Meds causing inattentiveness Nutrition Not enough or too much Inadequate rest Worked too many hours Unreported disqualifying medical condition Not notifying of seizure condition

Coordination/Communication/Planning Factors Task delegation Objectives not delegated to others Communicating critical information Did not inform of roof sagging Standard/proper terminology Using ten codes or slang with multi agency Challenge and reply Did not challenge leader of safety issue Mission planning Did not plan for the mission Mission briefing Did not brief crew of mission

Task/mission reevaluation Did not reevaluate objectives

Environmental Factors Physical Environment

Weather Adverse weather Terrain Driving down a grade Lighting Not enough lighting Toxins CO levels not monitored Vision restricted by icing/windows fogged etc Apparatus mirrors fogged while backing Vision restricted by meteorological conditions Apparatus strobes on during snow Vision restricted in workspace by dust/smoke etc Unable to see due to smoke conditions Wind Working in wind over 60mph

Developing HFACS 46

Thermal stress-cold Fighting fire at -10 F Thermal stress-heat Fighting fire at 95 F and 90% RH Lighting of other vehicle Driving toward high beams

Noise interference Unable to hear radio due to engine noise

Technological Environment Equipment/controls design Gauges not able to be seen while driving Seating and restraints Restraints don't fit over PPE Instrument and sensory feedback systems Ignored door open light Visibility restrictions Unable to see mirrors on apparatus Work environment incompatibility with human Apparatus does not accommodate tall driver Personal equipment interference Gloves do not work with coat Communication - equipment failure Portable radios do not work inside building

Unsafe Supervision Causal Factors Examples

INADEQUATE SUPERVISION Failed to provide proper training No firefighter survival training Failed to provide current adequate procedures Did not give proper up to date guidance Failed to recognize fatigue Did not notice fatigue Failed to track qualifications Unqualified individual performed ops Failed to track performance Did not ensure individual performance Failed to provide operational guidelines or policies Did not ensure SOG's followed Over-tasked supervisor Lost span of control Loss of supervisory situational awareness Got too deep for conditions Leadership/supervision/oversight inadequate Officer fighting fire instead of leading Supervision personality conflict Did not like crew Supervision lack of feedback Did not give critique Failed to hold crew responsible for actions Did not correct poor actions Lack of personnel accountability (where people are) Did not perform PAR

PLANNED INAPPROPRIATE OPERATIONS Poor crew pairing New officer new driver new back man Failed to provide adequate briefing Did not inform of conditions Risk outweighs benefit Fully involved house attempt rescue Failed to provide adequate opportunity for crew rest No rehab Excessive tasking/workload Exceeded span of control Ordered/led on mission beyond capability Fighting wild land in structural PPE Limited recent experience Officer driving after not driving 5 yrs Limited total experience One interior fire per year Proficiency No interior fires no interior fire training Risk assessment during size-up Did not do a walk around

Developing HFACS 47

Authorized unnecessary hazard Allowed unqualified individual to operate

FAILED TO CORRECT A KNOWN PROBLEM Failed to correct inappropriate behavior Did not provide discipline Failed to identify and correct risky behavior Allowed individual to take risk Failed to correct safety hazard Did not stop unsafe act Failed to initiate corrective action Failed to report unsafe tendencies Did not report continuous speeding Personnel management Did not ensure crew accountability

Operations management Did not have proper ICS

SUPERVISORY VIOLATIONS Authorized unqualified crew Allowed non 1403 FF in live burn Failed to enforce rules and regulations Did not discipline Violated procedures Sent crew in swift water w/o PFD Authorized unnecessary hazard Allowed crew to remove SCBA in IDLH Willful disregard for authority by supervisors Did not have crew exit when instructed Documentation incorrect or incomplete Falsified certification

Organizational Influences Causal Factors Examples

RESOURCE MANAGEMENT Human Resources

Selection Firefighters selected based on no physical requirements

Staffing/manning Not meeting NFPA 1710 or 1720

Training Not requiring 1403 before live burn

Monetary/Budget Resources Excessive cost cutting Reduction of personnel due to finance

Lack of funding Can not purchase new PPE

Equipment/Facility Resources Poor design Truck designed overweight Purchasing of unsuitable equipment Purchasing low bid

Failure to correct known design flaws Equipment in cab not secured

Resource/Acquisition Management Operator support Individual without proper PPE Acquisition process Purchases delayed due to bureaucracy Attrition Excessive leaving of organization Accession/selection Officers selected subjectively Personnel resources Not enough people to do the job

Informational resources/support Communication open up and down the organization

Developing HFACS 48

ORGANIZATIONAL CLIMATE Structure

Chain of Command Administration or operators did not use chain Communication Information does not go up and down Accessibility/visibility of supervisor Supervisor does not work with the crew Delegation of authority Supervisor micromanages crew

Formal accountability for actions Supervisor does not conduct performance evaluation

Policies Promotion Organization does not have job descriptions Hiring, firing, retention Organization does not have a dismissal policy Drugs and alcohol Organization does not have an alcohol policy

Accident investigations Organization does not have an investigation program

Culture

Norms and rules Rule states always have 2 in 2 out but norm is to go in

Organizational customs To alienate rookies until they prove themselves

Values, beliefs, attitudes Organization has little regard for safety at fires

ORGANIZATIONAL PROCESS Operations

Operational tempo The IC rushes the operation

Social pressures The public is saying that there is someone in a fire

Organization The Incident Mgmt system not organized Time pressure The organization expects arrival in 5 min

Management No ICS on the scene

Procedures Performance standards Organization does not evaluate performance Clearly defined objectives Objectives are not identified or stated

Procedures/instructions about procedures No instructions of technical procedure

Oversight Established safety/risk mgmt programs No risk management or safety program Organizational training issues/programs No up to date training on light weight trusses Organizations ability to change Organization resistance to change Modern practices Organization deploys booster line on car fire Managements monitoring of resources, climate Organization does not analyze injuries and processes to ensure a safe work environment

To provide a more fluid understanding of the HFACS system illustrating the divisions, categories,

subcategories, and causal factors a flow chart was developed and is located in the appendix

(appendix B).

Developing HFACS 49

Once the focus group evaluated and refined the system, it was utilized in evaluating

firefighter fatality reports from NCOSFM files to determine its effectiveness. In most reports that

were assessed, the primary area which could be evaluated was unsafe acts. Due to the lack of

information contained in the reports, it was difficult or impossible to definitively determine the

preconditions to unsafe acts, supervisory issues, and organizational issues. The focus group then

attempted to answer the preconditions to unsafe acts, supervisory issues, and organizational

issues by interjecting hypothetical information in the fatality reports to evaluate the tool. The

hypothetical information provided a better understanding of the analysis to complete an HFACS

evaluation; however it was only hypothetical data. To further ensure the effectiveness of the tool

each participant had the opportunity to provide a major incident from their organization and

utilize HFACS to evaluate the incident.

The evaluation of actual incidents with HFACS and the causal factors which had been

identified provided several conclusions:

1. Every incident produced multiple causal factors. There was no one factor that could

be traced back to be the definitive cause. There were multiple factors that would have

prevented the incident.

2. Every evaluation identified behaviors which could be modified or changed to prevent

future incidents from occurring.

3. Every incident evaluated provided organizational factors that played a role in the

incident occurring or if changed would have prevented the incident from occurring.

4. Identifying causal factors in all four divisions; unsafe acts, preconditions to unsafe

acts, supervisory issues, and organizational issues provided a complete analysis of the

incident and all factors involved instead of only focusing on the individual.

Developing HFACS 50

Discussion

It is evident through the evaluation that firefighter fatalities and injuries have only

declined by the decline of structure fires. USFA (2008) Structural collapse fatalities have even

seen an increase in the last eight years evaluated. NIST (2003) Understanding why firefighters

are being injured and killed is identified in broad factors that do not provide specific measurable

behaviors that can be changed. To identify injury prevention measures based on information

available focusing on the high probability identified would include; firefighters between the age

of 20 to 39, overexerting or straining, during fire development, extinguishing the fire or

neutralizing the incident (USFA, 2008). With the above highest percentage of factors identified,

the preventative behaviors may be as follows:

1. Target Audience – Firefighters ages 20 to 39

2. Objective- Teach firefighters not to overexert or strain themselves while extinguishing

the fire during the growth stage of the fire.

The above target audience and objective has some value; however, the broadness of the

statement might as well be a simplified statement – “don’t put the fire out”. Another example of

the broadness of what kills firefighters in structural collapse is identified by nature of death and

cause. Nature of death in structural collapse includes: asphyxiation, burns, internal trauma, and

other causes. The cause of firefighter deaths in structural collapse include caught or trapped, or

struck or had contact with an object (NIST, 2004).

Moore-Merrell, et al (2008) provided a deeper insight into contributing factors. Though

the data was clustered, it provided several contributing factors as the leading causes. These

causes grouped together included; decision making, lack of communication, standard operating

guideline or procedure breech, protocol breech, human error, lack of situational awareness, crew

Developing HFACS 51

size, lack of wellness or fitness, fatigue and weather or act of nature. One discrepancy found of

the cluster is that all of the factors in the cluster with the exception of weather or act of nature are

human error factors. The research did identify lack of situational awareness as the dominating

contributing factor.

James Reason (1990), Douglas Wiegmann and Scott Shappell (2003), and the Naval

Safety Center (2006) provided a framework that specified methods of identifying causal factors.

The need for specific measurable modifiable behaviors can be identified in causal factors.

Change will only be made to the operator if the operator is the only place an analysis is focused.

The Human Factor Analysis Classification System provided a focus beyond the operator into

preconditions, supervision and the organization. The Risk Assessment Code matrix also provided

a valuable example of a tool to identify the probability and severity of an incident defining the

level of risk it caused.

Jennings (2008), the Department of Transportation (2007), the Department of Defense,

the Australian Transportation Safety Bureau (2007) and Salmon (2008) identified uses of

HFACS in multiple fields. With HFACS being originally created for aviation the uses in other

fields provided a greater path in developing HFACS for the fire service. The most relative

industry to the fire service in the area of job skills was identified by Jennings (2008) in the

utilization of HFACS in the combat arena of Iraq.

The fire service utilizes a common term in public education called the three E’s. The

three E’s include education, engineering and enforcement. Salmon (2008) utilizing HFACS to

identify public issues with road ways highlighted the three E’s. The fire service should learn

from itself. To prevent injuries and fatalities we must identify the education, engineering, and

enforcement needs. The education needs to be done by identifying the specific and measurable

Developing HFACS 52

risk behaviors that can be changed. The fire service needs to ensure that engineering in human

factors is a top priority. The leaders both formal and informal of the fire service need to enforce

safe behaviors at all times.

Dekker (2006) provided good theory in accident investigation. The most prominent area

Dekker outlined was the reference to “The Old View” and “The New View”. The old view can

be classified as the operator did something wrong that caused the incident to occur. The new

view simply states that the evaluator should not look at the results and should put himself in the

shoes of the operator while attempting to understand the environment, situation, and information

the operator encountered which lead to the decisions made. The operator predominately did not

intentionally want to cause an adverse event to occur and if the evaluator can identify the

decisions of the operator without hindsight bias they may determine the operator did the best

they could do with what the organization provided.

To understand factors effecting the organization the book by Weick and Stucliffe (2007)

Managing the Unexpected was utilized. The theory of High Reliability Organizations is based on

organizations that either make few errors or recover rapidly from errors. The four areas of an

HRO includes: preoccupation with failure or always identifying symptoms, reluctance to

simplify or not being complacent, sensitivity to operations or management being attentive to the

job, and commitment to resilience or keeping errors small. An organization utilizing HFACS

would be a prime example of a High Reliability Organization.

To understand decision making, Klein (1998 & 2003) provided studies performed in the

fire service and military. The primary focus on firefighter decision making was a theory of

recognition-primed decision making. The brief synopsis of recognition-primed decision making

can be defined as decisions which are not made as the individual reacts to the environment.

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Further explanation of recognition-primed decision making is - the mind is a slide show of

previous experiences. When the firefighter encounters an environment, the mind pulls the slide

closest to the environment and utilizes that slide or previous experience to deal with the current

situation. Klein also recognizes that poor decisions are actually only poor outcomes, due to the

fact that the individual made the decision based on the information and expertise at the time of

the incident.

Recommendations

The development of the Human Factor Analysis Classification System for the fire service

has identified itself as a valuable tool producing information that can be formulated into specific

measurable objectives. The development of the system divisions, categories, subcategories and

causal factors indicate the functions and performance of the fire service.

In the future the development of HFACS for the fire service will always be evolving as

the fire service evolves. The program must be initiated to determine if further refinement is

needed through evaluating multiple incidents deriving from different incident types. The HFACS

should be delivered in a beta form with further evaluation of incidents to ensure if the program

captures too much or too little data. The evaluation of the data collected will further evaluate the

necessary causal codes. The system once evaluated in beta form and utilized should be evaluated

annually to ensure data needs are being maintained.

To best utilize the HFACS to its fullest extent identifying the shortcomings of the

organization an evaluator without ties to the organization would be least bias. With the difficulty

in identifying your own shortcomings and providing those to management, utilizing an outside

evaluator would be most effective. For the best results, an evaluation of an adverse incident

should consist of a formal investigation completed by the organization affected with an HFACS

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evaluation. The evaluation should be conducted by outside evaluators with the assistance of a

formal investigation team. If the effected organization can classify itself as a High Reliability

Organization, (one that can accept failure as a tool to improve operations) the organization may

be able to complete the formal and HFACS evaluation with internal personnel.

In addition to the HFACS, the Risk Assessment Codes (RAC) would provide great

insight into the severity and probability that specific types of incidents pose. The identification of

the RAC could be utilized to determine the extent or need of evaluation using HFACS. Every

incident should provide the information defined by the RAC: critical risk, serious risk, moderate

risk, minor risk, and negligible risk.

The value of utilizing the HFACS developed for the fire service identified itself while

evaluating previous incidents. Skyland Fire Rescue will need to implement the use of the

HFACS on all future incidents. Skyland’s utilization of the tool will provide insight into human

error on the levels of the operator, supervisor, and the organization. The HFACS does not need

to replace the formal investigation which details all of the specific information of the incident;

however, it should supplement the investigation by providing insight into human error and

preventable measures.

To provide a path in North Carolina to prevent firefighter injuries and fatalities, utilizing

HFACS with a specific incident would be the most effective method of collecting data. The best

practice would be to utilize the HFACS for all incidents; however, without some parameters this

may be an extreme task for the fire service. The Naval Safety Center’s (2006) severity

classification provides a starting parameter of Class B incidents creating $200,000 of damage or

more and injuries resulting in permanent or partial disability. Utilizing the “Three E’s of

Education” might provide a pathway for implementations. Education on evaluating incidents

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utilizing HFACS should be provided to a group of evaluators in each region of North Carolina;

West, Piedmont, and East. Every fire department should be provided with basic information and

benefits of the program. Engineering of HFACS should be provided through continual evaluation

of the system. Enforcement and support would be maintained by the Insurance Industry requiring

the data of Class B incident to be compiled to reduce injuries and damages thus reducing claims

and liability.

If HFACS was utilized by the National Institute of Safety and Health’s (NIOSH)

Firefighter Fatality Investigation and Prevention Program (FFFIPP), human errors would be

identified from the operator to the organization. The HFACS evaluation would provide specific

and measurable behaviors which could be identified and disseminated throughout the fire service

to change behaviors. To prevent placing blame on the organization, the data obtained by NIOSH

FFFIPP could be captured, compiled, and presented as an annual document.

The long term goal of utilizing the HFACS program would be accomplished through a

software program which would allow the evaluator to manage the documentation. Software

development should be accomplished and provided through the United States Fire

Administration with instructions on usage. The software system should have an option of an

automatic upload of the data to a national database without using department or personnel

information. The national database would provide the specific behaviors needing to be changed

in the fire service.

In summary the following short and long term recommendations would lead to

identification of preventable specific and measurable behaviors causing injuries and fatalities in

the fire service.

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1. Utilize the identified HFACS system for the fire service as a beta tool for

further evaluation with annual assessments after full release.

2. Utilize outside evaluators to assist in identifying organizational shortcomings.

3. Identify all incidents utilizing the Risk Assessment Codes to provide severity

and probability.

4. Implement the HFACS program at Skyland Fire Rescue as a supplement to

formal investigations to provide a complete incident analysis.

5. Implement the HFACS program in North Carolina on incidents with damage of

$200,000 or more and injuries with permanent or partial disability, using

trained evaluators in each region, supported by the insurance industry.

6. Provide the NIOSH FFFIPP with the HFACS evaluation tool to collect

summative data for annual reports.

7. Establish long term goals for the development of a HFACS software collection

tool and national database to be provided and managed by the USFA

coordinating with the IAFC National Firefighter Near-Miss Reporting System.

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Reference List Australian Transport Safety Bureau. (2007). Human Factor Analysis of Australian Aviation Accidents and Comparison with the United States. Australian Government.Retrieved July 2, 2008, from http://www.atsb.gov.au/publications/2007/pdf/b20040321.pdf Brunacini, A. V. (2008). Fast/Close/Wet. Paper presented in symposium on Reducing Firefighter Deaths and Injuries: Changes in Concept, Policy, and Practice. Public Entity Risk Institute. Retrieved September 23, 2008, from http://www.riskinstitute.org/peri/images/file/S908-D2-Brunacini.pdf Cole, R. M. (2007). Identifying a Risk Evaluation Tool to Prevent Injuries and Fatalities. Emmitsburg, MD: National Fire Academy. Dekker, S. (2006). The Field Guide to Understanding Human Error (2nd ed.). Burlington, VT: Ashgate Publishing Company. Jennings, J. (2008). Human Factors Analysis & Classification Applying the Department of Defense System During Combat Operations in Iraq. Professional Safety, 44-51. Retrieved July 2, 2008, from http://www.asse.org/professionalsafety/docs/JenningsFeature_0608.pdf Klein, G. (1998). Sources of Power: How people make decisions. Cambridge, MA: Massachusetts Institute of Technology. Klein, G. (2003). The Power of Intuition. New York, NY: Doubleday.

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Reference List Moore-Merrell, L., Zhou, A., McDonald-Valentine, S., Goldstein, R., & Slocum C. (2008). Contributing Factors to Firefighter Line-Of-Duty Injury in Metropolitan Fire Departments in the United States. International Association of Fire Fighters. Retrieved October 13, 2008, from http://www.iaff.org/08News/PDF/InjuryReport.pdf National Fallen Firefighters Foundation. (2005). Report of the National Fire Service Research Agenda Symposium. NFFF. Retrieved June 16, 2008, from http://www.fsi.uiuc.edu/documents/research/National%20Fire%20Service%20Re search%20Agenda%20Symposium.pdf National Institute of Standards and Technology. (2008). Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002. NIST. Retrieved June 15, 2008, from http://www.fire.nist.gov/bfrlpubs/fire03/PDF/f03024.pdf North Carolina Fatality Reports - 2008 - North Carolina Office of State Fire Marshal Fatality Database [Data file] Raleigh, NC: NCOSFM Reason, J. (1990). Human Error. New York: Cambridge University Press. Salmon, P., Regan, M., & Johnston, I. (2006). In A Systems perspective on Road User Error in Australia: Swiss cheese and the road transport system. Monash University Accident Research Center. Retrieved July 9, 2008, from http://www.monash.edu.au/muarc/reports/muarc257.pdf

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Reference List Shappell, S., & Wiegmann, D. (2006). Developing a Methodology for Assessing Safety Programs Targeting Human Error in Aviation. Federal Aviation Administration. Retrieved June 19, 2008, from http://stinet.dtic.mil/cgi- bin/GetTRDoc?AD=ADA461400&Location=U2&doc=GetTRDoc.pdf United States Department of Defense. (2003). Department of Defense Human Factors Analysis and Classification System. Retrieved June 17, 2008, from http://safetycenter.navy.mil/hfacs/downloads/hfacs.pdf United States Department of Transportation. (2007). Human Error Investigation Software Tool. Retrieved June 9, 2008, from http://www.fra.dot.gov/downloads/Research/ord0715.pdf United States Fire Administration / National Fallen Firefighters Foundation (2004, April 14). Firefighter Life Safety Summit Initial Report. Retrieved August 3, 2007, from http://www.firehero.org/s567/images/Initial_Summit_Report.pdf United States Fire Administration. (2008). Fire-Related Firefighter Injuries in 2004. USFA. Retrieved June 14, 2008, from http://www.usfa.dhs.gov/downloads/pdf/publications/2004_ff_injuries.pdf United States Naval Safety Center. (2006). The Naval Flight Surgeon's Pocket Reference to Aircraft Mishap Investigation (6th ed.). Retrieved November 9, 2008, from http://www.safetycenter.navy.mil/AVIATION/aeromedical/downloads/PocketRef erencepdf Weick, K. E., & Sutcliffe, K. M. (2007). Managing The Unexpected (2nd ed.). San Francisco, CA: John Wiley & Sons, Inc.

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Reference List Wiegmann, D. A., & Shappell, S. A. (2003). A Human Error Approach to Aviation Accident Analysis: The human factors analysis and classification system. Burlington, VT: Ashgate Publishing Company. Wiegmann, D., & Bouquet, A. (2005). Human Error and General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS. Washington: Federal Aviation Administration. Retrieved June 17, 2008, from http://stinet.dtic.mil/cgi- bin/GetTRDoc?AD=ADA460866&Location=U2&doc=GetTRDoc.pdf

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Appendix B

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