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THE HUMAN FACTORS ANALYSIS AND THE HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) CLASSIFICATION SYSTEM (HFACS) Scott Shappell, Ph.D. Civil Aerospace Medical Institute Douglas Wiegmann, Ph.D. University of Illinois

THE HUMAN FACTORS ANALYSIS AND CLASSIFICATION …Perceptual Errors Decision Errors Skill-Based Errors Errors SKILL-BASED ERRORS ¾Attention Failures - Breakdown in visual scan - Inadvertent

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Shappell & Wiegmann, 2002

THE HUMAN FACTORS ANALYSIS AND THE HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS)CLASSIFICATION SYSTEM (HFACS)

Scott Shappell, Ph.D.Civil Aerospace Medical Institute

Douglas Wiegmann, Ph.D.University of Illinois

Shappell & Wiegmann, 2002

Shappell & Wiegmann, 2002

Source: Boeing

0

10

20

30

40

50

1960

1970

1980

1990

Scheduled Air CarrierScheduled Air Carrier

0

10

20

30

40

50

1950

1960

1970

1980

1990

2000

Acc

iden

ts/1

00,0

00 fl

ight

hou

rs

U.S. General AviationU.S. General Aviation

Source: NTSB

0

10

20

30

40

1950

1960

1970

1980

1990

2000

Acc

iden

ts/1

00,0

00 fl

ight

hou

rs

U.S. Air ForceU.S. Air Force

Source: U.S. Air Force Safety Center

0

10

20

30

40

50

60

1950

1960

1970

1980

1990

2000

Acc

iden

ts/1

00,0

00 fl

ight

hou

rs

U.S. Navy/Marine CorpsU.S. Navy/Marine Corps

Source: U.S. Naval Safety Center

Shappell & Wiegmann, 2002

The rate of improvement has slowed significantly and substantially during the last 25 years.

This has led some to conclude that further reductions in accident rates are improbable, if not impossible.

REASONS FOR CONCERN

Shappell & Wiegmann, 2002

The rate of improvement has slowed significantly and substantially during the last 10 years.

This has led some to conclude that further reductions in accident rates are improbable, if not impossible.

REASONS FOR CONCERN

Still, aircraft are becoming increasingly expensive raising the cost of aviation accidents.

Total:$3.9 Billion

Aviation$3.3BAviation$3.3B

COST OF ACCIDENTSCOST OF ACCIDENTSCOST OF ACCIDENTSU.S. Navy and Marine CorpsU.S. Navy and Marine Corps

FY96FY96--0000

Shore/Ground$150M

Shore/Ground$150M

Shipboard$277M

ShipboardShipboard$277M$277M

PMV$129MPMV$129M

Recreation$67M

Recreation$67M

Source: U.S. Naval Safety CenterSource: U.S. Naval Safety CenterSource: U.S. Naval Safety CenterShappell & Wiegmann, 2000

Shappell & Wiegmann, 2002

U.S. Navy/Marine Corps (1950U.S. Navy/Marine Corps (1950--2000)2000)

0

10

20

30

40

50

60

1950

1960

1970

1980

1990

2000

Acc

iden

ts/1

00,0

00 fl

ight

hou

rs

Source: U.S. Naval Safety Center

Shappell & Wiegmann, 2002

All NAVY/MARINE Class A, B, & C MishapsAll NAVY/MARINE Class A, B, & C Mishaps

Cla

ss A

, B,&

C M

isha

ps/1

00,0

00 F

light

Hou

rsC

lass

A, B

,& C

Mis

haps

/100

,000

Flig

ht H

ours

00

22

44

66

88

1010

1212

1414

1616

1977

1977

1979

1979

1981

1981

1983

1983

1985

1985

1987

1987

1989

1989

1991

1991

YearYear

Mechanical

Human

Shappell, S. and Wiegmann, D. (1996). U.S. Naval aviation mishaps 1977-1992: Differences between single and dual-piloted aircraft. Aviation, Space, and Environmental Medicine, 67, 65-69.

Shappell & Wiegmann, 2002

Mechanical Failure

- Catastrophic failures are infrequent events

- When failures do occur, they are often less severe or hazardous due to effective intervention programs.

Data-DrivenResearch

Accident Investigation

- Highly sophisticated techniques and procedures

- Information is objective and quantifiable

- Effective at determining why the failure occurred

Database Analysis

- Traditional analyses are clearly outlined and readily performed.

- Frequent analyses help identify common mechanical and engineering safety issues.

Miti

gatio

n

Prev

entio

n

EffectiveIntervention

and Prevention Programs

- Designed around traditional categories

- Variables are well-defined and causally related

- Organization and structure facilitate access and use

Accident Database

Feedback

Research Sponsors

- FAA, DoD, NASA, & airplane manufacturers provide research funding.

- Research programs are needs-based and data-driven. Interventions are therefore very effective.

Wiegmann, D. & Shappell, S. (2001). Human error analysis of commercial aviation accidents: Application of the Human Factors Analysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine,72, 1006-1016.

Shappell & Wiegmann, 2002

Feedback

Human Error

- Errors occur frequently and are the major cause of accidents.

- Few safety programs are effective at preventing the occurrence or consequences of these errors.

Research Sponsors

- FAA, DoD, NASA, & Airlines provide funding for safety research programs.

- Lack of good data leads to research programs based primarily on interests and intuitions. Interventions are therefore less effective.

Fad-DrivenResearch

Miti

gatio

n

Prev

entio

n

IneffectiveIntervention

and Prevention Programs

Accident Investigation

- Less sophisticated techniques and procedures

- Information is qualitative and illusive

- Focus on “what” happened but not “why” it happened

Accident Database

- Not designed around any particular human error framework

- Variables often ill-defined

- Organization and structure difficult to understand

Database Analysis

- Traditional human factors analyses are onerous due to ill-defined variables and database structures.

- Few analyses have been performed to identify underlying human factors safety issues.

Wiegmann, D. & Shappell, S. (2001). Human error analysis of commercial aviation accidents: Application of the Human Factors Analysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine,72, 1006-1016.

Shappell & Wiegmann, 2002

Shappell, S. and Wiegmann, D. Controlled flight into terrain: The utility of an information processing approach to mishap causal factors. Proceedings of the Eighth Symposium for Aviation Psychology, Ohio State University, 1300-1306, 1995.

Wiegmann, D and Shappell, S. Human factors in U.S. Naval aviation mishaps: An information processing approach. Proceedings of the Eighth Symposium for Aviation Psychology, Ohio State University, 1995.

Wiegmann, D. and Shappell, S. Human factors analyses of post-accident data: Applying theoretical taxonomies of human error. International Journal of Aviation Psychology, 7, 67-81, 1997.

Wiegmann, D. and Shappell, S. Human error perspectives in aviation. International Journal of Aviation Psychology, 11, 341-357, 2001.

What was required, therefore, was a general human error framework around which accident investigation and prevention programs can be developed.

We explored several approaches and “off-the-shelf” frameworks

ADDRESSING THE PROBLEMADDRESSING THE PROBLEM

CognitiveErgonomics AeromedicalPsychosocialOrganizational

Shappell & Wiegmann, 2002

The Human Factors Analysis and Classification The Human Factors Analysis and Classification System (HFACS)System (HFACS)

Shappell, S. and Wiegmann, D. A human error approach to accident investigation: The Taxonomy of Unsafe Operations. International Journal of Aviation Psychology, 7, 269-291, 1998.

Shappell, S. and Wiegmann, D. Human factors analysis of aviation accident data: Developing a needs-based, data-driven, safety program. Proceedings of the HESSD, Brussels, Belgium, 1999.

Shappell, S. and Wiegmann, D. The Human Factors Analysis and Classification System – HFACS. Office of Aviation Medicine Technical Report No. DOT/FAA/AM-00/7. Civil Aeromedical Institute, Oklahoma City, OK 73125, 2000.

Shappell, S. and Wiegmann, D. Beyond Reason: Defining the holes in the Swiss Cheese. Human Factors in Aviation Safety, (in press), 2000.

Shappell & Wiegmann, 2002

Active ConditionsFailed to scan instruments

Penetrated IMC when VFR only

UnsafeActs

Adapted from Reason (1990)

Failed orAbsent Defenses

Breakdown of a Productive SystemBreakdown of a Productive System

Shappell & Wiegmann, 2002

Active and Latent ConditionsPoor CRM

Loss of situational awareness

Failed orAbsent Defenses

Preconditionsfor

Unsafe Acts

UnsafeActs

Adapted from Reason (1990)

Active ConditionsFailed to scan instruments

Penetrated IMC when VFR only

Breakdown of a Productive SystemBreakdown of a Productive System

Shappell & Wiegmann, 2002

Latent ConditionsDeficient training program

Improper crew pairing

Active and Latent ConditionsPoor CRM

Loss of situational awareness

Failed orAbsent Defenses

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Adapted from Reason (1990)

Active ConditionsFailed to scan instruments

Penetrated IMC when VFR only

Breakdown of a Productive SystemBreakdown of a Productive System

Shappell & Wiegmann, 2002

Latent ConditionsExcessive cost cutting

Inadequate promotion policies

Latent ConditionsDeficient training program

Improper crew pairing

Active and Latent ConditionsPoor CRM

Loss of situational awareness

Failed orAbsent Defenses

OrganizationalFactors

InputsEconomic inflation

Few qualified pilots

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Adapted from Reason (1990)

Accident & InjuryCrashed into side ofmountain

Active ConditionsFailed to scan instruments

Penetrated IMC when VFR only

Breakdown of a Productive SystemBreakdown of a Productive System

Shappell & Wiegmann, 2002

UNSAFEACTS

UNSAFEACTS

ViolationsErrorsErrors

ExceptionalRoutinePerceptualErrors

DecisionErrors

Skill-BasedErrors

UnsafeActs

Shappell & Wiegmann, 2002

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

DecisionErrors

DECISION ERRORSRule-based Decisions

- If X, then do Y- Highly Procedural

Choice Decisions- Knowledge-based

Ill-Structured Decisions- Problem solving

UnsafeActs

Shappell & Wiegmann, 2002

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Skill-BasedErrors

SKILL-BASEDERRORS

Attention Failures- Breakdown in visual scan- Inadvertent operation of control

Memory Failure- Omitted item in checklist- Omitted step in procedureStick-and-Rudder Skills

UnsafeActs

Shappell & Wiegmann, 2002

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

PerceptualErrors

ErrorsErrors

PERCEPTUALERRORS(due to)

Misjudge Distance,Altitude, AirspeedSpatial DisorientationVisual Illusions

UnsafeActs

Shappell & Wiegmann, 2002

Exceptional

Violations

Routine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

Violations

Routine

ROUTINE (INFRACTIONS)(Habitual departures from rules condoned by management)

VFR Flight into IMCElected to File VFR in Marginal Weather ConditionsFailed to Use Radar Advisories from ATCInadequate Brief and Limits on MissionIFR Procedure Not FollowedWeight and Balance ExceededProcedure/Directives Not FollowedOperating With Known DeficienciesMin. Descent Altitude not Complied with

UnsafeActs

Shappell & Wiegmann, 2002

Routine

Violations

Exceptional

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors Exceptional

UNSAFEACTS

UNSAFEACTS

Violations

Exceptional

EXCEPTIONAL(Isolated departures from the rules not condoned

by management)

Violated NATOPS/Regulations/SOP- Performed Unauthorized Acrobatic Maneuver- Canyon Running- Failed to Complete Performance Computations for Flight- Failed to Obtain Valid Weather Brief

Accepted Unnecessary HazardNot Current/Qualified for MissionExceeded Limits of Aircraft

UnsafeActs

Shappell & Wiegmann, 2002

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Preconditionsfor

Unsafe Acts

UnsafeActs

PRECONDITIONSFOR

UNSAFE ACTS

Shappell & Wiegmann, 2002

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

ADVERSE MENTAL STATE

Adverse Mental States

Loss of Situational AwarenessCircadian dysrhythmiaAlertness (Drowsiness)OverconfidenceComplacencyTask Fixation

Condition of Operators

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

Adverse Physiological

States

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Environmental Factors

Preconditionsfor

Unsafe Acts

UnsafeActs

Adverse Physiological

States

Condition of Operators

ADVERSE PHYSIOLOGICALSTATES

Spatial DisorientationVisual IllusionsG-induced Loss of ConsciousnessHypoxiaMedical Illness

Shappell & Wiegmann, 2002

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Preconditionsfor

Unsafe Acts

UnsafeActs

Condition of Operators

Physical/Mental

Limitations

PHYSICAL/MENTALLIMITATIONS

Lack of Sensory InputLimited Reaction TimeIncompatible Physical CapabilitiesIncompatible Intelligence/Aptitude

Shappell & Wiegmann, 2002

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Preconditionsfor

Unsafe Acts

UnsafeActs

Personnel Factors

Crew Resource Management

CREW RESOURCEMANAGEMENT

Not Working as a TeamPoor Aircrew CoordinationImproper Briefing Before a MissionInadequate Coordination of Flight

Shappell & Wiegmann, 2002

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Preconditionsfor

Unsafe Acts

UnsafeActs

Personnel Factors

Personal Readiness

PERSONAL READINESSReadiness Violations

Crew Rest RequirementsBottle-to-Brief RulesSelf-Medicating

Poor JudgementPoor Dietary PracticesOverexertion While Off Duty

Shappell & Wiegmann, 2002

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Preconditionsfor

Unsafe Acts

UnsafeActs

Environmental Factors

Physical Environment

PHYSICAL ENVIRONMENT

WeatherLightingNoiseHeatAccelerationVibrationPollutants

Shappell & Wiegmann, 2002

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Preconditionsfor

Unsafe Acts

UnsafeActs

Environmental Factors

Technological Environment

TECHNOLOGICAL ENVIRONMENT

Equipment and controlsAutomation reliability/complexityTask and Procedure DesignManuals and Checklist DesignInterfaces and Displays

Shappell & Wiegmann, 2002

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

UNSAFESUPERVISION

UNSAFESUPERVISION

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

InadequateSupervision

INADEQUATE SUPERVISIONFailure to Administer Proper TrainingLack of Professional Guidance

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

UNSAFESUPERVISION

UNSAFESUPERVISION

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

PlannedInappropriate

Operations

PLANNED INAPPROPRIATEOPERATIONS

Mission Risk without BenefitImproper Work TempoPoor Crew Pairing

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UNSAFESUPERVISION

UNSAFESUPERVISION

Failed toCorrectProblem

FAILED TO CORRECT AKNOWN PROBLEM

Failure to Correct Inappropriate BehaviorFailure to Correct a Safety Hazard

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

UNSAFESUPERVISION

UNSAFESUPERVISION

UNSAFESUPERVISION

SupervisoryViolations

SUPERVISORY VIOLATIONSNot Adhering to Rules and RegulationsWillful Disregard for Authority by

Supervisors

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

Shappell & Wiegmann, 2002

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

ResourceManagement

ResourceManagement

ORGANIZATIONALINFLUENCES

RESOURCE MANAGEMENTHumanMonetaryEquipment/Facility

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

ORGANIZATIONALINFLUENCES

OrganizationalClimate

ORGANIZATIONALCLIMATE

StructurePoliciesCulture

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

OrganizationalClimate

ResourceManagement

ResourceManagement

OperationalProcess

ORGANIZATIONALINFLUENCES

ORGANIZATIONALINFLUENCES

OperationalProcess

OPERATIONALPROCESSOperationsProceduresOversight

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Shappell & Wiegmann, 2002

Errors

UNSAFEACTS

Errors

PerceptualErrors

Skill-BasedErrors

DecisionErrors ExceptionalRoutine

Violations

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

ResourceManagement

OrganizationalClimate

OrganizationalProcess

ORGANIZATIONALINFLUENCES

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Shappell & Wiegmann, 2002

Shappell & Wiegmann, 2002

OrganizationalFactors

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Intervention: Filling the Holes in the Cheese

SafeSupervision

Preconditionsfor

Safe Acts

SafeDecisions

SafeActs

Shappell & Wiegmann, 2002

U.S. NAVY/MARINE CORPSU.S. NAVY/MARINE CORPS

AVIATION ACCIDENT DATAAVIATION ACCIDENT DATAShappell, S. and Wiegmann, D. Is proficiency eroding among U.S. Shappell, S. and Wiegmann, D. Is proficiency eroding among U.S. Naval aircrews? A quantitative analysis using the Naval aircrews? A quantitative analysis using the

Human Factors Analysis and Classification System. Proceedings ofHuman Factors Analysis and Classification System. Proceedings of the the 4444thth Annual Meeting of the Human Factors Annual Meeting of the Human Factors and Ergonomics Societyand Ergonomics Society, San Diego, California, 2000., San Diego, California, 2000.

Shappell, S.,Shappell, S., SquierSquier, H.,, H., AbadAbad, G., and Wiegmann, D. An analysis of U.S. Navy and Marine Corps, G., and Wiegmann, D. An analysis of U.S. Navy and Marine Corps mishaps using the mishaps using the failure analysis classification system: Implications for preventfailure analysis classification system: Implications for prevention. ion. 69th Annual Meeting of the Aerospace Medical 69th Annual Meeting of the Aerospace Medical AssociationAssociation, 1998., 1998.

Shappell, S., Wiegmann, D., Fraser, J., Gregory, G., Kinsey, P.,Shappell, S., Wiegmann, D., Fraser, J., Gregory, G., Kinsey, P., andand SquierSquier, H. Beyond mishap rates: A human factors , H. Beyond mishap rates: A human factors analysis of U.S. Navy/Marine Corps TACAIR and Rotary Wing mishapanalysis of U.S. Navy/Marine Corps TACAIR and Rotary Wing mishaps using HFACS. 70s using HFACS. 70th Annual Meeting of the th Annual Meeting of the Aerospace Medical AssociationAerospace Medical Association, 1999., 1999.

Shappell, S., Wiegmann, D., Fraser, J., Tanner, G., Kinsey, P., Shappell, S., Wiegmann, D., Fraser, J., Tanner, G., Kinsey, P., andand ReddixReddix, M. Tracking aircrew error trends in Naval , M. Tracking aircrew error trends in Naval aviation mishaps using HFACS. aviation mishaps using HFACS. 71st Annual Meeting of the Aerospace Medical Association71st Annual Meeting of the Aerospace Medical Association, 2000., 2000.

Shappell & Wiegmann, 2002

Aircraft Control Not MaintainedProcedures/Directives Not FollowedAbort DelayedAirspeed (VREF) Not MaintainedAPU SelectedProper Touchdown Point MisjudgedAbort Above V1 ImproperAirspeed (VMC) Not MaintainedAutopilot Improper Use OfComplacencyControl Interference InadvertentCrew/Group Coordination Not MaintainedProper Touchdown Point Not AttainedAirspeed Not MaintainedAirspeed (VR) ImproperAutopilot Inadvertent DeactivationCircuit Breaker SelectedCompensation for Wind Conditions Not PossibleFlare ImproperUnsafe/Hazardous Condition Not IdentifiedVFR Flight Into IMC AttemptedFlight Into Adverse Weather ContinuedHydraulic System Not SelectedInadequate Surveillance of OperationProper Touchdown Point Not PossibleAborted Takeoff DelayedAirspeed (VLOF) Not AttainedAirspeed ExcessiveAltimeter Setting Not ObtainedAltitude Not MaintainedBecame Lost/DisorientedChecklist Not Complied WithCrew/Group Coordination Not PerformedFlaps Improper Use OfFlare ExcessiveFlight into Known Adverse Weather InitialedGo-Around Not PerformedIdentification of Aircraft Visually DelayedInadequate Substantiation ProcessVisual Separation Not MaintainedMinimum Descent Altitude Not MaintainedWheels Up Landing InadvertentAircraft Preflight Not PerformedAircraft Weight and Balance MisjudgedAltimeter Not UsedChecklist Inaccurate

Compensation For Wind Conditions InadequateDescent ExcessiveDistance MisjudgedFlare DelayedGround Loop/Swerve IntentionalRemedial Action DelayedVFR Flight Into IMP InitiatedVisual Lookout Not MaintainedAbort Above V1 PerformedCompensation for Wind Conditions ImproperDirectional Control Not MaintainedDiverted AttentionIce/Frost Removal From Aircraft InadequateIFR Procedure ImproperAircraft Control Not PossibleStall InadvertentInadequate Visual LookoutLack of Familiarity With AircraftLack of Total Experience in Type of AircraftLowering of Flaps PerformedPressureVFR Flight Into IMC InadvertentAborted Takeoff PerformedCommunications Not UnderstoodEmergency Procedure Not FollowedInadequate Weather EvaluationNosewheel Steering ExcessiveProcedure InadequateRotation ExcessiveVFR Flight into IMC ContinuedEmergency Procedure Not PerformedLack of Familiarity with Geographic AreaLevel Off Not AttainedMaintenance, Adjustment ImproperMonitoring InadequatePropeller Feathering Not PerformedRemedial Action Not PossibleVisual/Aural PerceptionPreflight Planning/Preparation InadequateAircraft Handling ImproperCrew/Group Coordination InadequateSpoiler Extension Not PerformedStall/Spin InadvertentAirspeed (VREF) Not AttainedAirspeed (VS) Not MaintainedGo-Around Delayed

Fatigue (Flight and Ground Schedule)Flight to Alternation Not PerformedOperation with Known Deficiencies in EquipmentSpoiler Extension Inadvertent ActivationSupervision InadequatePlanning/Decision improperRaising of Flaps ImproperIn-Flight Planning/Decision ImproperOverconfidence in Personal AbilityParking Brake Not SetExpectancyFlight Manuals Improper Use OfWrong Taxi Route SelectedGear Extension Not PerformedWeather Evaluation InadequateStall/Mush EncounteredParking Brakes Inadvertent DeactivationIn-Flight Planning/Decision PoorProper Glidepath Not MaintainedAltitude InadequateConditions/Steps Insufficiently DefinedEvacuation ImproperPassenger Briefing InadequateSpatial DisorientationThrottle/Power Control Improper Use OfWeather Evaluation InaccurateWrong Runway SelectedIce/Frost Removal From Aircraft Not IdentifiedPlanned Approach PoorRecovery from Bounced Landing ImproperPlanning/Decision InadequateAircraft Preflight InadequateChecklist InadequateDescent InadvertentGenerator Inadvertent DeactivationTouchdown InadvertentPreflight Planning/Preparation ImproperCompensation for Wind Conditions MisjudgedVisual IllusionUncontrolled DescentProper Descent Rate Not MaintainedChecklist Not UsedAnti-Ice/Deice System Not UsedInadequate MonitoringPowerplant Controls Inadvertent ActivationTraffic Advisory Not Identified

Clearance MisjudgedIFR Procedure Not FollowedInattentiveRemedial Action AttemptedSomeone GoofedImproper Use of Preflight Briefing ServiceDescent PrematureProper Descent Rate Not AttainedAirspeed Not Maintained (generic)Inadvertent StallVisual Lookout InadequateIce/Frost Removal From Aircraft Nor PerformedInformation InsufficientSelf-Induced PressureTrim Setting ImproperFlight Controls Improper Use OfAltitude/Clearance Not MaintainedManeuver PerformedPreflight Planning/Preparation PoorProper Altitude Not MaintainedFlare InitiatedFlight Advisories Not FollowedAltitude/Clearance InadequateDistance/Altitude MisjudgedInadequate TrainingRotation ImproperUnsuitable Terrain or Takeoff/Landing/Taxi AreaVFR Procedures InadequateProper Alignment Not PossibleRemedial Action ImproperFlare MisjudgedProper Alignment DelayedMissed Approach Not PerformedProper Alignment Not AttainedLack of Total Experience in Type OperationMinimum Descent Altitude BelowMiscellaneous Equipment InitiatedProper Alignment Not MaintainedSupervision ImproperGear Down and Locked Not VerifiedWind Information MisjudgedAircraft Weight and Balance ExceededAircraft Control-UncontrolledCrew/Group Coordination Not AttainedChecklist Not FollowedClearance Not Maintained

Sample of the Types of Human Error Typically FoundSample of the Types of Human Error Typically Found

Shappell & Wiegmann, 2002

Count (%) Count (%)

USMCn=73

USNn=105

Organizational InfluencesResource ManagementOrganizational ClimateOrganizational Process

Unsafe SupervisionInadequate SupervisionPlanned Inappropriate OperationsFailed to Correct a Known ProblemSupervisory Violations

Preconditions for Unsafe ActsAdverse Mental StatesAdverse Physiological StatesPhysical/Mental LimitationsCrew Resource MismanagementPersonal Readiness

Unsafe ActsDecision ErrorsSkill-based ErrorsPerceptual ErrorsViolations

170

19

18948

57187

402

36382322

(23)(0)(26)

(25)(12)(5)(11)

(78)(25)(10)(55)(3)

(49)(52)(32)(30)

32139

27111011

792711695

64572833

(30)(1)

(37)

(26)(10)(10)(10)

(75)(26)(10)(66)(5)

(61)(54)(27)(31)

Number and Percentage of Mishaps Associated with EachHFACS Causal Category (FY 91-99)

Number and Percentage of Mishaps Associated with EachHFACS Causal Category (FY 91-99)

Shappell & Wiegmann, 2002

Violations

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

VIOLATIONS

Violation of Orders/Regulations/SOP- Failed to Inspect ACFT after In-Flight Caution Light- Violated Squadron SOP Restricting Flight Below 500’- Failed to Comply with NATOPS During Streaming- Conducted Night Training and Ops Mission with PAX- Elected to File VFR in Marginal Weather Conditions- Failed to Use Radar Advisories from ATC- Inadequate Brief and Limits on Mission- HAC Knowingly Accepted Non-Current Crew

Failed to Adhere to BriefNot Current/Qualified for MissionImproper Procedure

Shappell & Wiegmann, 2002

0

10

20

30

40

50

91 92 93 94 95 96 97 98 99Fiscal Year

Perc

enta

g e

Percentage of Human Error Mishaps Associated with Violations (FY 91-97)Percentage of Human Error Mishaps Associated with Violations (FY 91-97)

ρρ==--.487, ns.487, ns

Shappell & Wiegmann, 2002

Intervention StrategyIntervention Strategy

ProfessionalismProfessionalismAccountabilityAccountabilityEnforcing the RulesEnforcing the Rules

Shappell & Wiegmann, 2002

0

10

20

30

40

50

91 92 93 94 95 96 97 98 99Fiscal Year

Perc

enta

g e

Percentage of Human Error Mishaps Associated with Violations (FY 91-99)

Percentage of Human Error Mishaps Associated with Violations (FY 91-99)

Shappell & Wiegmann, 2002

UnsafeActs

Violations

ExceptionalRoutine

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

PerceptualErrors

DecisionErrors

Skill-BasedErrors

UNSAFEACTS

UNSAFEACTS

ErrorsErrors

Skill-BasedErrors

SKILL-BASED ERRORSBreakdown in Visual ScanFailed to See and AvoidPoor TechniqueOmitted Checklist ItemInadvertent Operation of ControlImproper Use of Flight Controls

Shappell & Wiegmann, 2002

Percentage of Human Error Mishaps Associated withSkill-based Errors (FY 91-99)

Percentage of Human Error Mishaps Associated withSkill-based Errors (FY 91-99)

0

10

20

30

40

50

60

70

80

91 92 93 94 95 96 97 98 99Fiscal Year

Perc

enta

g e

ρρ=.832, p<.01=.832, p<.01

Shappell & Wiegmann, 2002

Preliminary Intervention StrategyPreliminary Intervention Strategy

Improve instrument scanImprove instrument scanPrioritizing attentionPrioritizing attentionRecognizing extremis situationsRecognizing extremis situationsRefine basic flight skills (StickRefine basic flight skills (Stick--andand--Rudder)Rudder)Practice proceduresPractice proceduresReview the mishap database!Review the mishap database!

Shappell & Wiegmann, 2002

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Preconditionsfor

Unsafe Acts

UnsafeActs

Personnel Factors

Crew Resource Management

CREW RESOURCEMANAGEMENT

Not Working as a TeamPoor Aircrew CoordinationImproper Briefing Before a MissionInadequate Coordination of Flight

Shappell & Wiegmann, 2002

0

10

20

30

40

50

60

70

80

91 92 93 94 95 96 97 98 99Fiscal Year

Perc

enta

g e

Percentage of Human Error Mishaps Associated withCrew Resource Management Failures (FY 91-98)

Percentage of Human Error Mishaps Associated withCrew Resource Management Failures (FY 91-98)

ρρ=.551, ns=.551, ns

Percentages do not add up to 100%

Shappell & Wiegmann, 2002

Platform specific trainingPlatform specific trainingUse of video feedbackUse of video feedbackRestructure tasks (i.e., EP’s)Restructure tasks (i.e., EP’s)

Preliminary Intervention StrategyPreliminary Intervention Strategy

Change group compositionChange group compositionAttempt to change attitudesAttempt to change attitudesAdditional research...Additional research...

Shappell & Wiegmann, 2002

0

10

20

30

40

50

60

70

80

91 92 93 94 95 96 97 98 99Fiscal Year

Perc

enta

g e

Percentage of Human Error Mishaps Associated withCrew Resource Management Failures (FY 91-99)

Percentage of Human Error Mishaps Associated withCrew Resource Management Failures (FY 91-99)

Percentages do not add up to 100%

Shappell & Wiegmann, 2002

Feedback

Human Error

- Errors occur frequently and are the major cause of accidents.

- Few safety programs are effective at preventing the occurrence or consequences of these errors.

Research Sponsors

- FAA, DoD, NASA, & Airlines provide funding for safety research programs.

- Lack of good data leads to research programs based primarily on interests and intuitions. Interventions are therefore less effective.

Fad-DrivenResearch

Miti

gatio

n

Prev

entio

n

IneffectiveIntervention

and Prevention Programs

Accident Investigation

- Less sophisticated techniques and procedures

- Information is qualitative and illusive

- Focus on “what” happened but not “why” it happened

Accident Database

- Not designed around any particular human error framework

- Variables often ill-defined

- Organization and structure difficult to understand

Database Analysis

- Traditional human factors analyses are onerous due to ill-defined variables and database structures.

- Few analyses have been performed to identify underlying human factors safety issues.

Accident Investigation

- Sophisticated techniques and procedures

- Information is qualitative and quantitative

- Focus on both “what” happened and “why”

Accident Database

- Designed around a well-known human error framework

- Well-defined variables

- Organization and structure easy to understand

FeedbackFeedback

Human Error

- Errors occur less frequently.

- Safety programs are effective at preventing the occurrence or consequences of these errors.

- FAA, DoD, NASA, & Airlines provide funding for safety research programs.

- Research programs are needs-based and data-driven. Interventions are therefore very effective.

Research Sponsors

Fad-DrivenResearch

Data-DrivenResearch

EffectiveIntervention

and Prevention Programs

Database Analysis

- Traditional human factors analyses are much less onerous due to well-defined variables and error database

- Analyses can now be performed to identify human factors safety issuesHFACSHFACS

Shappell & Wiegmann, 2002

Errors

UNSAFEACTS

Errors

PerceptualErrors

Skill-BasedErrors

DecisionErrors ExceptionalRoutine

Violations

InadequateSupervision

PlannedInappropriate

Operations

Failed toCorrectProblem

SupervisoryViolations

UNSAFESUPERVISION

ResourceManagement

OrganizationalClimate

OrganizationalProcess

ORGANIZATIONALINFLUENCES

PRECONDITIONSFOR

UNSAFE ACTS

Condition of Operators

Physical/Mental

Limitations

Adverse Mental States

Technological Environment

Physical Environment

Personal Readiness

Crew Resource Management

Personnel Factors

Adverse Physiological

States

Environmental Factors

Shappell & Wiegmann, 2002

HFACS can be applied anywhere! HFACS can be applied anywhere!

FlightdeckFlightdeck(HFACS)(HFACS)

MaintenanceMaintenance(HFACS(HFACS--ME)ME)

ATCATC(HFACS(HFACS--ATC)ATC)??