Review And Analysis Of Events

Question 1

Define:

Human Factors Analysis and Classification System (HFACS)

Answer 1

• A systems approach at analyzing events, with human error viewed as a symptom of a larger problem and not the cause.
• Barriers are established to prevent adverse events, they are divided into 4 sequential categories:
  
  1. Organizational Influence
  2. Unsafe Supervision
  3. Preconditions
  4. Unsafe Acts
• Within each level, failures can cause holes in safety barriers. In theory, 1 failures will occur at each category leading to an adverse event.

Question 2

HFACS

What are the 2 types of failures?

Answer 2

1. Active Failures: Occur immediately prior to the accident and directly impact the event.
2. Latent Failures: Removed temporarily from the event and do not exhibit a direct impact.

Question 3

HFACS

List the HFACS framework.

Answer 3

Organizational Influences
1. Organizational Culture
2. Operational Process
3. Resource Management

Supervisory Factors
1. Inadequate Supervision
2. Planned Inappropriate Operations
3. Failure to Correct Known Problems
4. Supervisory Violation

Preconditions for Unsafe Acts
- Situational/Environmental Factors:
1. Physical Environment
2. Tools/Technological Environment
- Condition of the Operator:
1. Altered Mental States
2. Altered Physical States
3. Physical/Mental Limitations
- Personnel Factors:
1. Communication/Coordination/Planning
2. Fitness for Duty

Unsafe Acts
- Errors
1. Decision Errors
2. Skill-Based Errors
3. Perceptual Errors
- Violations
1. Routine Violations
2. Exceptional Violations

Question 4

HFACS

List and define:

Organizational Influences

(3)

Answer 4

Organizational Climate (OC)
- Prevailing atmosphere/vision within the organization including such things as policies, command structure, and culture.

Operational Process (OP)
- Formal process by which the vision of an organization is carried out, including operations, procedures, and oversight among others.

Resource Management
- How human, monetary, and equipment resources necessary to carry out the vision are managed.

Question 5

HFACS

List and define:

Unsafe Supervision

(4)

Answer 5

Inadequate Supervision (IS)
- Oversight and management of personnel and resources, including training, professional guidance, and operational leadership among other aspects.

Planned Inappropriate Operations (PIO)
- Management and assignment of work including aspects of risk management, crew pairing, operational tempo, etc.

Failure to Correct Known Problems (FCP)
- Those instances when deficiencies among individuals, equipment, training, or other related safety areas are “known” to the supervisor, yet are allowed to continue uncorrected.

Supervisory Violations (SV)
- The wilful disregard for existing rules, regulations, instructions, or standard operating procedures by management during the course of their duties.

Question 6

HFACS

List and define:

Preconditions for Unsafe Acts

(2/3/2)

Answer 6

Situational/Environmental Factors

Physical Environment (PhyE)
- Includes both the operational setting (weather, altitude, terrain) and the ambient environment (heat, vibrations, lighting, toxins, etc.).

Tools/Technological Environment (TE)
- Encompasses a variety of issues including the design of equipment and controls, display/interface characteristics, checklist layouts, task factors, and automation.

Condition of the Operator

Altered Mental States (AMS)
- Acute psychological and/or mental conditions that negatively affect performance (mental fatigue, pernicious attitudes, misplaced motivation).

Altered Physical States (APS)
- Acute medical and/or physiological conditions that preclude safe operations (illness, intoxication, pharmacological, etc.).

Physical/Mental Limitations (PML)
- Permanent physical/mental disabilities that way adversely affect performance (poor vision, lack of physical strength, mental aptitude, general knowledge, etc.).

Personnel Factors

Communication/Coordination/Planning (CC)
- A variety of communication, coordination, and teamwork issues that impact performance.

Fitness for Duty (FD)
- Off-duty activities required to perform optimally on the job such as adhering to crew rest requirements, alcohol restrictions, and other off-duty mandates.

Question 7

HFACS

List and define:

Unsafe Acts

(3/2)

Answer 7

Errors

Decision Errors (DE)
- “Thinking Errors”
- Represent conscious, goal-intended behavior that proceeds as designed, yet the plan proved inadequate or inappropriate for the situation.
- Typically manifests as poorly executed procedures, improper choices, or simply the misunderstanding/misuse of relevant information.

Skill-Based Errors (SBE)
- “Doing Errors”
- Highly practiced behavior that occurs with little or no conscious thought.
- Frequently appears as breakdown in visual/scan patterns, inadvertent activation/deactivation of switches, forgotten intentions, and omitted items in checklists.
- Even the manner or technique with which one performs a task is included.

Perceptual Errors (PE)
- Arise when sensory input is degraded as is often the case when flying at night, in poor weather, or in otherwise visually impoverished environments.
- Acting with imperfect and/or incomplete information.

Violations

Routine Violations (RV)
- “Bending the Rules”
- Tends to be habitual in nature and is often enabled by a system of supervision and management that tolerates such departures from the rules.

Exceptional Violations (EV)
- Isolated departures from authority, neither typical of the individual nor condoned by management.

Question 8

What are the steps for performing a Root Cause Analysis (RCA)?

(5)

Answer 8

1. Define the Problem
2. Collect Data
3. Identify Possible Causal Factors
4. Identify the Root Cause(s)
5. Recommend and Implement Solutions