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In doing so, HFACS allows safety professionals to identity
all of the factors that influence performance and cause
operators to err. As illustrated in Figure 4, these factors
include cognitive and physiological variables, contextual and
technological components, and communication and
interpersonal interactions. Also included, but often
overlooked, are those supervisory and organizational factors
that directly influence the causal chain of events. In other
words, the HFACS framework goes beyond the simple
identification of what an operator did wrong to provide a
clear understanding of the reasons why the error occurred in
the first place. In this way, errors are viewed as
consequences of system failures, and/or symptoms of
deeper systemic problems. They are not simply the fault of
the employee working the “pointy end of the spear.”
Errors
UNSAFE
ACTS
Perceptual
Errors
Skill-Based
Errors
Decision
Errors Routine Exceptional
Violations
Inadequate
Supervision
Planned
Inappropriate
Operations
Failed to
Correct
Problem
Supervisory
Violations
UNSAFE
SUPERVISION
Resource
Management
Organizational
Climate
Organizational
Process
ORGANIZATIONAL
INFLUENCES
PRECONDITIONS
FOR
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
Figure 4. The Human Factors Analysis and
Classification System (HFACS).
We originally developed HFACS as an aviation accident
investigation and analysis tool for the U.S. Navy and Marine
Corps. However, HFACS has since been adopted by all
branches of the U.S. military, as well as the Canadian
Defense Force as a tool for analyzing the role of human
error in military aviation accidents. It is now also widely
utilized by civil aviation organizations around the world,
including the Federal Aviation Administration (FAA) and
National Aeronautics and Space Administration (NASA), as
an adjunct to their preexisting safety management systems.
This is not to say that HFACS is only applicable to aviation.
Indeed, it has also been proven effective in the analysis of
errors within a variety of other industrial settings, including
healthcare, mining, and manufacturing. Given its theoretical
foundation, HFACS can be applied in virtually any
operational context.
Error Management Solutions
Human Factors Analysis and Classification System
®
Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 4
Copyright Error Management Solutions, LLC 2004
Identifying the causes of human error, however, is only half
the battle in the prevention of incidents and accidents. The
development and implementation of effective intervention
programs that reduce the occurrence or consequences of
errors is the next critical step in the safety management
process. Toward these ends, we recently developed the
tools and methodology for mapping intervention strategies
onto specific forms of human error identified within the
HFACS model. Our tool, coined the Human Factors
Intervention matriX (HFIX®) allows safety professionals to
systematically generate comprehensive intervention
strategies that directly target specific error categories, as well
as their underlying causes (see Figure 5).
DDeecciissiioonn
EErrrroorrss
SSkkiillll--based
EErrrroorrss
PPeerrcceeppttuuaall
EErrrroorrss
VViioollaattiioonnss
OOrrggaanniizzaattiioonnaall//
Administrative
Human/
CCrreeww
Technology/
EEnnggiinneeeerriinngg
TTaasskk//
Mission
Operational/
Physical
EEnnvviirroonnmmeenntt
Figure 5. The Human Factors Intervention matriX
(HFIX).
However, HFIX does not stop at simply identifying
interventions. Rather, the model guides safety professionals
when evaluating the potential efficacy of intervention
strategies. For instance, as illustrated in Figure 6, other
factors that need to be considered before implementing any
intervention are cost, feasibility, and acceptability. All of
these, and others, are captured during the process of
applying the HFIX methodology.
FFeeaassiibbiilliittyy
Cost
Effectiveness
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