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 in the 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 DoD HFACS version 8.0 was designed to accommodate all occupational communities throughout the DoD and intended for use by safety personnel, data research personnel and commanders in three inter-related areas.
1. Provide a structured tool that aids safety personnel in explaining the linkage between complex layers of underlying organizational weaknesses/root causes and an individual’s active failure and/or severity of damage or injury. 2. Improve mishap prevention strategies by using this tool during pre-mission planning and safety inspection as an aid to identify the underlying organizational weaknesses/root causes of hazards and hazardous conditions in order to develop more effective risk controls. 3. Provide data research personnel with a standard, data-driven approach which meets the intent of DoDI 6055.07 to “Establish procedures to provide for the cross-feed of human error data using a common human error categorization system that involves human factors taxonomy accepted among the DoD components”.
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.
Errors that occur when the operator’s/aviator’s/worker’s execution of a routine or highly practiced task related to a procedure, training or proficiency was performed incorrectly and resulted in a near-miss or mishap.
When the individual pursued an inappropriate course of action after intentionally or unintentionally failing to accurately assess a situation, which resulted in a near miss or mishap.
Known, intended and deliberate deviations from known standards, rules, regulations, instructions, or procedures by the mishap operator/aviator/worker. These codes only apply when the negative outcome (near-miss or mishap) was unintended.
When the mishap individual experienced a failure in attention management which negatively affected the mishap individual’s perception and/or performance and resulted in a hazardous condition or unsafe act.
When psychosocial problems, life stressors, personality traits, or misplaced motivation of the mishap individual created a hazardous condition or unsafe acts.
NOTE: When using PC200 codes, ensure you consult with a qualified medical professional.
When an individual experienced a physiologic condition that compromised performance and resulted in a hazardous condition or unsafe acts.
NOTE: When using any of the PC300 codes, ensure you give strong consideration to consulting with qualified professionals who specialize in the areas of physiology, as defined by your service.
Conditions related to the immediate physical surroundings which negatively affected individual performance, resulting in unsafe acts.
When workspace design conditions or automation affected the actions of individuals and resulted in a hazardous condition or unsafe acts. This includes ground vehicle systems, aircraft, watercraft/shipboard spaces, control stations, weapons systems, communication systems, maintenance repair systems, etc.
Verbal or non-verbal interactions among crews/teams involved with the preparation and/or execution of a task/mission, which resulted in hazardous conditions or unsafe acts. This includes failures with communication between members of aircraft, tactical vehicles, ground guides, boat or ship, stevedore/long shoring, or any other crew/team communication failures.
When formal or informal instruction, skill development or knowledge limit the individual’s capability, capacity or performance resulting in an unsafe act.
When the unspoken or unofficial rules, values, attitudes, beliefs, and customs of small unit leaders or their higher organization negatively affected good order and discipline in adherence to established safety standards, initiatives, and practices.
Factors when a supervisor/leader willfully disregarded instructions, guidance, policies, rules or standard operating procedures. This includes failing to enforce standards, allowing unwritten practices to become standard, directing individuals to violate existing rules/regulations and authorizing unqualified personnel for a task.
A factor when supervisory/leadership personnel failed to properly identify and assess hazards, mitigate risks, ensure personnel are effectively trained and informed, and/or provide effective guidance and oversight, which resulted in hazardous conditions or unsafe acts.
Factors when unit leadership failed to effectively utilize the troop leading procedures/risk management process to assess hazards and develop effective controls associated with an activity, event, mission or operation, which resulted in unnecessary risk.
Latent failures where the unspoken or unofficial rules, values, attitudes, beliefs, and customs of organizational level leadership negatively affected lower-level working environment or practices resulting in hazardous conditions or unsafe acts throughout subordinate units or the field/fleet.
Latent failures whereby flaws in an organization’s safety management system (standards, policies, procedural guidance, doctrine, processes, or governance/program management) negatively influenced leader/supervisory or individual performance.
Latent failures when resource support or system safety inadequacies resulted in ineffective risk management or created hazardous conditions for leaders/supervisors and/or the operator/aviator/worker.
When a training and/or educational program of instruction designed to improve technical, tactical, critical thinking or leadership skills is incorrect, incomplete or insufficient for performance to standard, which negatively influenced supervisor/leader and/or individual performance.
Human factors are the leading cause of DoD mishaps. The DoD HFACS model presents a systematic, multidimensional approach to error analysis and mishap prevention.
Transition Guidance
Refresher Training
HFACS 8.0 How-To Training
