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:
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.
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.
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.
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.
When a specific action is performed in a manner that leads to a mishap.
When personnel management processes or policies, directly or indirectly, influence system safety and result in poor error management or create an unsafe situation.
When the individual intentionally breaks the rules and instructions. Violations are deliberate.
When weather, climate, fog, brownout (dust or sandstorm) or whiteout (snowstorm) affect the actions of individuals.
When automation or the design of the workspace affects the actions of an individual.
Medical or physiological conditions that can result in unsafe situations.
When an individual's personality traits, psychosocial problems, psychological sidorders or inappropriatemotivation creates an unsafe situation.
When supervision fails to adequately plan or assess the hazards associated with an operation and allows for unnecessary risk.
Factors of an attention management or awareness failure that affects the perception or performance of individuals.
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.
When supervisors willfully disregard instructions or policies.
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.
When resources influence system safety, resulting in adequate error management or creating an unsafe situation.
When policies and processes negatively influence performance and result in an unsafe situation.
When the working atmosphere within the organization influences individual actions, resulting in human error (e.g. command structure, policies and working environment).
See AE100
Go to Q2
See AE200
Go to Q3
See AV000
Go to Q4
Go to Q4a
Go to Q5
See PE100
Go to Q4b
See PE200
Go to Q5a
Go to Q6
See PC300
Go to Q5b
See PC200
Go to Q5c
See PC500
Go to Q5d
See PC100
See PP100
Go to Q7
See SI000
Go to Q8
Go to Q7a.
Go to Q8.
See SV000
Go to Q7b
See SP000
Go to Q7c
Go to Q8a
No more questions
See OR000
Go to Q8b
See OS000
Go to Q8c
See OP000
Go to Q8d
See OC000
Human factors are the leading cause of DoD mishaps. The DoD HFACS model presents a systematic, multidimensional approach to error analysis and mishap prevention.
