DoD HFACS 7.0 Intro

Human factors describe how our interaction with tools, tasks, working environments, and other people influence human performance.

Human error remains the leading cause of DoD mishaps. Many investigators look only as far as the person(s) involved inthe mishap. However, the majority of mishaps have supervisory and/or organizational influences that lead to or contribute to their occurrence. Mishaps are rarely attributable to a single cause, but are often the end result of a series of errors.

The purpose of the HFACS guide is to aid the investigator through a systematic, multidimensional analysis of potential human factors to explain what and why a mishap occurred. It is designed for use by all members of an investigation board in order to accurately record all aspects of human performance associated with the individual and the mishap or event. DoD HFACS helps investigators:

Perform a more complete investigation
Classify particular actions (or inactions) that sustained the mishap sequence
Contribute to the AFSAS database as a repository for detecting mishap trends and preventing future mishaps

How HFACS Works
- Acts
  Start at the lowest level and ask, "What did the person do, or not do, to cause the mishap?" This is the "Acts" level.
  
  Maybe the mishap person pushed the wrong button, made a bad decision, and/or violated a rule or regulation; select the Acts nanocodes that apply to your situation.
- Preconditions
  Next, ask, "Why did that persondo this unsafe act?" This is the "Preconditions" level.
  
  Perhaps the mishap person was fatigued, going through a divorce, complacent or trying to accomplish the procedure in bad weather. Read about the Preconditions nanocodes and pick those that apply.
- Supervision
  Now that you know the preconditions for the individual, look at what supervision's role was in the mishap
  
  Many times we find that someone in the supervisory chain knew about the mishapperson's preconditions, but didn't take steps to prevent the mishap. Perhaps there were SOPs in place, but they were unclear or not enforced.
- Organizational Influences
  
  Finally, look at the organization as a whole.
  
  Perhaps the mishap person was given procedures to use that were unclear or the training they received was inadequate. It could also be that budget issues or the improperselection of personnel were factors.
- Swiss Cheese Model

HFACS Nanocodes

Acts
- Performance-Based Errors (AE100)
  When a specific action is performed in a manner that leads to a mishap.
  - AE103 Procedure Not Followed Correctly
  - AE104 Overcontrolled/Undercontrolled Aircraft/Vehicle/System
  - AE105 Breakdown in Visual Scan
  - AE107 Rushed or Delayed a Necessary Action
- Judgement & Decision-Making Errors (AE200)
  When personnel management processes or policies, directly or indirectly, influence system safety and result in poor error management or create an unsafe situation.
  - AE201 Inadequate Real‐Time Risk Assessment
  - AE202 Failure to Prioritize Tasks Adequately
  - AE205 Ignored a Caution/Warning
  - AE206 Wrong Choice of Action During an Operation
- Violations (AV000)
  When the individual intentionally breaks the rules and instructions. Violations are deliberate.
  - AV001 Performs Work‐Around Violation
  - AV002 Commits Widespread/Routine Violation
  - AV003 Extreme Violation – Lack of Discipline
Preconditions
- Physical Environment (PE100)
  When weather, climate, fog, brownout (dust or sandstorm) or whiteout (snowstorm) affect the actions of individuals.
  - PE101 Environmental Conditions Affecting Vision
  - PE103 Vibration Affects Vision or Balance
  - PE106 Heat/Cold Stress Impairs Performance
  - PE108 External Force or Object Impeded an Individual’s Movement
  - PE109 Lights of Other Vehicle/Vessel/Aircraft Affected Vision
  - PE110 Noise Interference
- Technological Environment (PE200)
  When automation or the design of the workspace affects the actions of an individual.
  - PE201 Seat and Restraint System Problems
  - PE202 Instrumentation and Warning System Issues
  - PE203 Visibility Restrictions (not weather related)
  - PE204 Controls and Switches are Inadequate
  - PE205 Automated System Creates an Unsafe Situation
  - PE206 Workspace Incompatible with Operation
  - PE207 Personal Equipment Interference
  - PE208 Communication Equipment Inadequate
- Physical Problem (PC300)
  Medical or physiological conditions that can result in unsafe situations.
  - PC302 Substance Effects (alcohol, supplements, medications, drugs)
  - PC304 Loss of Consciousness (sudden or prolonged onset)
  - PC305 Physical Illness/Injury
  - PC307 Fatigue
  - PC310 Trapped Gas Disorders
  - PC311 Evolved Gas Disorders
  - PC312 Hypoxia/Hyperventilation
  - PC314 Inadequate Adaptation to Darkness
  - PC315 Dehydration
  - PC317 Body Size/Movement Limitations
  - PC318 Physical Strength & Coordination (inappropriate for task demands)
  - PC319 Nutrition/Diet
- State of Mind (PC200)
  When an individual's personality traits, psychosocial problems, psychological sidorders or inappropriatemotivation creates an unsafe situation.
  - PC202 Psychological Problem
  - PC203 Life Stressors
  - PC204 Emotional State
  - PC205 Personality Style
  - PC206 Overconfidence
  - PC207 Pressing
  - PC208 Complacency
  - PC209 Motivation
  - PC215 Mentally Exhausted (Burnout)
- Sensory Misperception (PC500)
  When supervision fails to adequately plan or assess the hazards associated with an operation and allows for unnecessary risk.
  - PC501 Motion Illusion – Kinesthetic
  - PC502 Turning/Balance Illusion – Vestibular
  - PC503 Visual Illusion
  - PC504 Misperception of Changing Environment
  - PC505 Misinterpreted/Misread Instrument
  - PC507 Misinterpretation of Auditory/Sound Cues
  - PC508 Spatial Disorientation
  - PC511 Temporal/Time Distortion
- Mental Awareness (PC100)
  Factors of an attention management or awareness failure that affects the perception or performance of individuals.
  - PC101 Not Paying Attention
  - PC102 Fixation
  - PC103 Task Over‐Saturation/Under‐Saturation
  - PC104 Confusion
  - PC105 Negative Habit Transfer
  - PC106 Distraction
  - PC107 Geographically Lost
  - PC108 Interference/Interruption
  - PC109 Technical or Procedural Knowledge Not Retained after Training
  - PC110 Inaccurate Expectation
- Teamwork (PP100)
  Interactions among individuals, crews and teams involved with the preparation and execution of a task/mission that resulted in human error or an unsafe situation.
  - PP101 Failure of Crew/Team Leadership
  - PP103 Inadequate Task Delegation
  - PP104 Rank/Position Intimidation
  - PP105 Lack of Assertiveness
  - PP106 Critical Information Not Communicated
  - PP107 Standard/Proper Terminology Not Used
  - PP108 Failed to Effectively Communicate
  - PP109 Task/Mission Planning/Briefing Inadequate
Supervision
- Supervisory Violations (SV000)
  When supervisors willfully disregard instructions or policies.
  - SV001 Failure to Enforce Existing Rules (supervisory act of omission)
  - SV002 Allowing Unwritten Policies to Become Standard
  - SV003 Directed Individual to Violate Existing Regulations
  - SV004 Authorized Unqualified Individuals for Task
- Planned Inappropriate Operations (SP000)
  When supervision fails to adequately plan or assess the hazards associated with an operation and allows for unnecessary risk.
  - SP001 Directed Task Beyond Personnel Capabilities
  - SP002 Inappropriate Team Composition
  - SP003 Selected Individual with Lack of Current or Limited Experience
  - SP006 Performed Inadequate Risk Assessment – Formal
  - SP007 Authorized Unnecessary Hazard
- Inadequate Supervision (SI000)
  When department-level or command-level supervision proves inappropriate or improper and/or fails to identify hazards, recognize and control risks or provide guidance, training and/or oversight.
  - SI001 Supervisory/Command Oversight Inadequate
  - SI002 Improper Role‐Modeling
  - SI003 Failed to Provide Proper Training
  - SI004 Failed to Provide Appropriate Policy/Guidance
  - SI005 Personality Conflict with Supervisor
  - SI006 Lack of Supervisory Responses to Critical Information
  - SI007 Failed to Identify/Correct Risky or Unsafe Practices
  - SI008 Selected Individual with Lack of Proficiency
Organizational Influences
- Resource Problems (OR000)
  When resources influence system safety, resulting in adequate error management or creating an unsafe situation.
  - OR001 Command and Control Resources are Deficient
  - OR003 Inadequate Infrastructure
  - OR005 Failure to Remove Inadequate/Worn‐Out Equipment in a Timely Manner
  - OR008 Failure to Provide Adequate Operational Information Resources
  - OR009 Failure to Provide Adequate Funding
- Personnel Selection & Staffing (OS000)
  When personnel management processes or policies, directly or indirectly, influence system safety and result in poor error management or create an unsafe situation.
  - OS001 Personnel Recruiting and Selection Policies are Inadequate
  - OS002 Failure to Provide Adequate Manning/Staffing Resources
- Policy & Process Issues (OP000)
  When policies and processes negatively influence performance and result in an unsafe situation.
  - OP001 Pace of Ops‐tempo/Workload
  - OP002 Organizational Program/Policy Risks not Adequately Assessed
  - OP003 Provided Inadequate Procedural Guidance or Publications
  - OP004 Organizational (formal) Training is Inadequate or Unavailable
  - OP005 Flawed Doctrine/Philosophy
  - OP006 Inadequate Program Management
  - OP007 Purchasing or Providing Poorly Designed or Unsuitable Equipment
- Climate/Cultural Influences (OC000)
  When the working atmosphere within the organization influences individual actions, resulting in human error (e.g. command structure, policies and working environment).
  - OC001 Organizational Culture (attitude/actions) Allows for Unsafe Task/Mission
  - OC003 Organizational Over‐confidence or Under‐confidence in Equipment
  - OC004 Unit Mission/Aircraft/Vehicle/Equipment Change or Unit Deactivation
  - OC005 Organizational Structure is Unclear or Inadequate
Chart

Benefits of DoD HFACS 7.0
- Structured analysis of human error
  - Detailed, complete and operationally focused
- Gets to the 'Why" not just the "What"
  - More accurate root cause determination
  - Permits more effective risk management
- A new data-driven approach
  - Supports research across the DoD
  - Easily applied to both new mishaps and previous reports
- Can be used for more than operational purposes
  - As a brainstorming tool for risk management
  - In developing interview questions
  - Applies to both on‐ and off‐duty mishaps

Investigation Questions

Acts
- Active Failures or Actions
- 1. Did the mishap person(s) make a performance-based error?
  - Yes
    See AE100
    
    Go to Q2
  - No
    Go to Q2
- 2. Was the mishap person(s)' action the result of poor judgement and/or decision making?
  - Yes
    See AE200
    
    Go to Q3
  - No
    Go to Q3
- 3. Did the mishap person(s) violate a commonly known law or regulation?
  - Yes
    See AV000
    
    Go to Q4
  - No
    Go to Q4
Preconditions
- Latent Failures or Conditions
- 4. Was the environment a factor in the mishap?
  - Yes
    Go to Q4a
  - No
    Go to Q5
- 4a. Did the physical environment affect the mishap person(s)?
  - Yes
    See PE100
    
    Go to Q4b
  - No
    Go to Q4b
- 4b. Did the technological environment affect the mishap person(s)?
  - Yes
    See PE200
    
    Go to Q5
  - No
    Go to Q5
- 5. Did the mishap person(s)' mental, sensory or physical state contribute to the mishap?
  - Yes
    Go to Q5a
  - No
    Go to Q6
- 5a. Did the mishap person(s) have a medical or physical condition?
  - Yes
    See PC300
    
    Go to Q5b
  - No
    Go to Q5b
- 5b. Did the mishap person(s)' state of mind create an unsafe situation?
  - Yes
    See PC200
    
    Go to Q5c
  - No
    Go to Q5c
- 5c. Was sensory information misperceived or misunderstood?
  - Yes
    See PC500
    
    Go to Q5d
  - No
    Go to Q5d
- 5d. Did the mishap person(s)' mental awareness create an unsafe situation?
  - Yes
    See PC100
    
    Go to Q6
  - No
    Go to Q6
- 6. Did challenges with teamwork contribute to the mishap?
  - Yes
    See PP100
    
    Go to Q7
  - No
    Go to Q7
Supervision
- 7c. Did a supervisor or supervision prove inadequate?
  - Yes
    See SI000
    
    Go to Q8
  - No
    Go to Q8
- Direct Supervisory Chain of Command
- 7. Did supervision or supervisory policies contribute to the mishap?
  - Yes
    Go to Q7a.
  - No
    Go to Q8.
- 7a. Did a supervisor violate a commonly known law or regulation?
  - Yes
    See SV000
    
    Go to Q7b
  - No
    Go to Q7b
- 7b. Did supervision fail to plan or assess known hazards?
  - Yes
    See SP000
    
    Go to Q7c
  - No
    Go to Q7c
Organizational Influences
- Upper Management, Command Level
- 8. Did the organization or organizational policies contribute to the mishap?
  - Yes
    Go to Q8a
  - No
    No more questions
- 8a. Did a problem with resources create an unsafe situation?
  - Yes
    See OR000
    
    Go to Q8b
  - No
    Go to Q8b
- 8b. Was selection of personnel or staffing a factor?
  - Yes
    See OS000
    
    Go to Q8c
  - No
    Go to Q8c
- 8c. Did an organizational instruction or policy create an unsafe situation?
  - Yes
    See OP000
    
    Go to Q8d
  - No
    Go to Q8d
- 8d. Did the safety climate/culture contribute to an unsafe situation?
  - Yes
    See OC000
  - No
    No more questions

DoD HFACS 7.0 Guide

Human factors are the leading cause of DoD mishaps. The DoD HFACS model presents a systematic, multidimensional approach to error analysis and mishap prevention.