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Human Factors Analysis Article
and Classification System Organisation
Information
(HFACS) Category:and Human
Performance
Definition Content
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The Human Factors Analysis and Classification
System (HFACS) was developed by Dr Scott Content
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control:
Shappell and Dr Doug Wiegmann. It is a
broad human error framework that was
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originally used by the U.S. Navy to investigate
and analyse human factors aspects of aviation.
HFACS is heavily based upon James
Reason's Swiss cheese model (Reason 1990).
The HFACS framework provides a tool to assist
in the investigation process and target
training and prevention efforts. Investigators
are able to systematically identify active and
latent failures within an organisation that
culminated in an accident. The goal of HFACS
is not to attribute blame; it is to understand
the underlying causal factors that lead to an
accident.
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The HFACS Framework
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The HFACS framework (Figure 1) describes
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human error at eachNo,ofgive
fourme more info
levels of failure:
1. Unsafe acts of operators (e.g., aircrew),
2. Preconditions for unsafe acts,
3. Unsafe supervision, and
4. Organisational influences.
Within each level of HFACS, causal categories
were developed that identify the active and
latent failures that occur. In theory, at least
one failure will occur at each level leading to
an adverse event. If at any time leading up to
the adverse event, one of the failures is
corrected, the adverse event will be prevented.
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Figure 1: The HFACS framework
HFACS Level 1: Unsafe Acts
The Unsafe Acts level is divided into two
categories - errors
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two categories
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userdivided into
experience
subcategories. Errors
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behaviors, while violations are a willful
disregard of the rules and regulations.
Errors
Skill-Based Errors: Errors which occur in the
operator’s execution of a routine, highly
practiced task relating to procedure, training
or proficiency and result in an unsafe
situation (e.g., fail to prioritise attention,
checklist error, negative habit).
Decision Errors: Errors which occur when the
behaviors or actions of the operators proceed
as intended yet the chosen plan proves
inadequate to achieve the desired end-state
and results in an unsafe situation (e.g,
exceeded ability, rule-based error,
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inappropriate procedure).
Perceptual Errors: Errors which occur when
an operator's sensory input is degraded and
a decision is made based upon faulty
information.
Violations
Routine Violations: Violations which are a
habitual action on the part of the operator
and are tolerated by the governing authority.
Exceptional Violations: Violations which are
an isolated departure from authority, neither
typical of the individual nor condoned by
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HFACS Levelthe2:Accept
By clicking Preconditions
button, you agree for
Unsafe
to usActs
doing so.
The Preconditions for Unsafe Acts level is
divided into three categories:
environmental factors,
condition of operators, and
personnel factors.
These three categories are further divided into
subcategories. Environmental factors refer to
the physical and technological factors that
affect practices, conditions and actions of
individual and which result in human error or
an unsafe situation. Condition of operators
refers to the adverse mental state, adverse
physiological state, and physical/mental
limitations factors that affect practices,
conditions or actions of individuals and result
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in human error or an unsafe situation.
Personnel factors refer to the crew resource
management and personal readiness factors
that affect practices, conditions or actions of
individuals, and result in human error or an
unsafe situation.
Environmental Factors
Physical Environment: Refers to factors that
include both the operational setting (e.g.,
weather, altitude, terrain) and the ambient
environment (e.g., heat, vibration, lighting,
toxins).
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Environment: to to factors
Refers
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that include your user
a variety experience
of design and
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automation issues including the design of
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equipment and controls, display/interface
characteristics, checklist layouts, task factors
and automation.
Condition of Operators
Adverse Mental State: Refers to factors that
include those mental conditions that affect
performance (e.g., stress, mental fatigue,
motivation).
Adverse Physiological State: Refers to factors
that include those medical or physiological
conditions that affect performance (e.g,
medical illness, physical fatigue, hypoxia).
Physical/Mental Limitations: Refers to the
circumstance when an operator lacks the
physical or mental capabilities to cope with a
situation, and this affects performance (e.g.,
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visual limitations, insufficient reaction time).
Personnel Factors
Crew Resource Management: Refers to
factors that include communication,
coordination, planning, and teamwork issues.
Personal Readiness: Refers to off-duty
activities required to perform optimally on
the job such as adhering to crew rest
requirements, alcohol restrictions, and other
off-duty mandates.
HFACS Level 3: Unsafe
Supervision
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The Unsafe Supervision
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four categories.
to us doing so.
Inadequate Supervision: The role of any
supervisor is to provide their staff with the
opportunity to succeed, and they must
provide guidance, training, leadership,
oversight, or incentives to ensure the task is
performed safely and efficiently.
Plan Inappropriate Operation: Refers to those
operations that can be acceptable and
different during emergencies, but
unacceptable during normal operation (e.g.,
risk management, crew pairing, operational
tempo).
Fail to Correct Known Problem: Refers to
those instances when deficiencies are known
to the supervisor, yet are allowed to continue
unabated (e.g, report unsafe tendencies,
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initiate corrective action, correct a safety
hazard).
Supervisory Violation: Refers to those
instances when existing rules and
regulations are willfully disregarded by
supervisors (e.g., enforcement of rules and
regulations, authorized unnecessary hazard,
inadequate documentation).
HFACS Level 4: Organisational
Influences
The Organisational Influences level is divided
into three
We categories.
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Resource your user experience
Management: Refers to the
By clicking the Accept button, you agree
organisational-level decision-making
to us doing so.
regarding the allocation and maintenance of
organisational assets (e.g., human resources,
monetary/budget resources,
equipment/facility recourse).
Organisational Climate: Refers to the
working atmosphere within the organisation
(e.g., structure, policies, culture).
Operational Process: Refers to organisational
decisions and rules that govern the everyday
activities within an organisation (e.g.,
operations, procedures, oversight).
Use of HFACS
By using the HFACS framework for accident
investigation, organisations are able to identify
the breakdowns within the entire system that
allowed an accident to occur. HFACS can also
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be used proactively by analyzing historical
events to identify reoccurring trends in
human performance and system deficiencies.
Both of these methods will allow
organisations to identify weak areas and
implement targeted, data-driven
interventions that will ultimately reduce
accident and injury rates.
HFACS provides a structure to review and
analyze historical accident and safety data. By
breaking down the human contribution to
performance, it enables the analyst to identify
the underlying factors on
We use cookies that aresite
this associated
to with
enhance
an unsafe your
act. The user experience
HFACS framework may also
By clicking
be useful as a toolthefor
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guiding you agree
future accident
to us doing
investigations in so.
the field and for developing
better accident databases, both of which
would improve the overall quality and
accessibility of human factors accident data.
Common trends within an organisation can
be derived from comparisons of psychological
origins of the unsafe acts, or from the latent
conditions that allowed these acts within the
organisation. Identifying those common
trends supports the identification and
prioritization of where intervention is needed
within an organisation. By using HFACS, an
organisation can identify where hazards have
arisen historically and implement procedures
to prevent these hazards which will result in
improved human performance and decreased
accident and injury rates. The US Navy was
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experiencing a high percentage of aviation
accidents associated with human
performance issues. Using the HFACS
framework, the Navy was able to identify that
nearly one-third of all accidents were
associated with routine violations. Once this
trend was identified, the Navy was able to
implement interventions that not only
reduced the percentage of accident
associated with violations, but sustained this
reduction over time.
Application of HFACS
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While the first use
enhance of user
your the HFACS
experienceframework
occurred in the US
By clicking theNavy where
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originated,
agree
the system has spread
to us doing so. to a variety of industries
and organizations (e.g. mining, construction,
rail and healthcare). Over the years, the
application reached civil and general aviation.
Organizations such as the Federal Aviation
Administration (FAA) and National
Aeronautics and Space Administration have
explored the use of HFACS as a complement
to pre-existing systems.
HFACS Taxonomy
The HFACS taxonomy describes four levels
within Reason's model and are described
below.
HFACS Level 1: Unsafe Acts
The Unsafe Acts level is divided into two
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categories - errors and violations - and these
two categories are then divided into
subcategories. Errors are unintentional
behaviours, while violations are a willful
disregard of the rules and regulations.
We use cookies on this site to
enhance your user experience
By clicking the Accept button, you agree
to us doing so.
Errors
Skill-Based Errors: Errors which occur in the
operator’s execution of a routine, highly
practiced task relating to procedure, training
or proficiency and result in an unsafe a
situation (e.g., fail to prioritize attention,
checklist error, negative habit).
Decision Errors: Errors which occur when the
behaviours or actions of the operators proceed
as intended yet the chosen plan proves
inadequate to achieve the desired end-state
and results in an unsafe situation (e.g,
exceeded ability, rule-based error,
inappropriate procedure).
Perceptual Errors: Errors which occur when
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an operator's sensory input is degraded and a
decision is made based upon faulty
information.
Violations
Routine Violations: Violations which are a
habitual action on the part of the operator and
are tolerated by the governing authority.
Exceptional Violations: Violations which are
an isolated departure from authority, neither
typical of the individual nor condoned by
management.
HFACS Level 2: Preconditions for
We use cookies on this site to
Unsafe Acts
enhance your user experience
The Preconditions
By clicking thefor Unsafe
Accept Actsyou
button, level is
agree
dividedtointo threeso.categories - environmental
us doing
factors, condition of operators, and personnel
factors - and these two categories are then
divided into subcategories. Environmental
factors refer to the physical and technological
factors that affect practices, conditions and
actions of individual and result in human error
or an unsafe situation. Condition of operators
refer to the adverse mental state, adverse
physiological state, and physical/mental
limitations factors that affect practices,
conditions or actions of individuals and result
in human error or an unsafe situation.
Personnel factors refer to the crew resource
management or TRM and personal readiness
factors that affect practices, conditions or
actions of individuals, and result in human
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error or an unsafe situation.
Environmental
We use cookiesFactors
on this site to
enhance your user experience
Physical Environment: Refers to factors that
By clicking the Accept button, you agree
include both the operational setting
to us doing so.
(e.g., weather, altitude, terrain) and the
ambient environment (e.g., heat, vibration,
lighting, toxins).
Technological Environment: Refers to factors
that include a variety of design and
automation issues including the design of
equipment and controls, display/interface
characteristics, checklist layouts, task factors
and automation.
Condition of Operators
Adverse Mental State: Refers to factors that
include those mental conditions that affect
performance (e.g., stress,
mental fatigue, motivation).
Adverse Physiological State: Refers to factors
that include those medical or physiological
KCABDEEF
conditions that affect performance (e.g,
medical illness, physical fatigue, hypoxia).
Physical/Mental Limitation: Refers to when
an operator lacks the physical or mental
capabilities to cope with a situation, and this
affects performance (e.g., visual limitations,
insufficient reaction time).
Personnel Factors
Crew Resource Management: Refers to
factors that include communication,
coordination, planning, and teamwork issues.
PersonalWeReadiness:
use cookiesRefers
on thistosite
off-duty
to
activities required
enhance to user
your perform optimally on the
experience
job suchByas adhering
clicking to crew
the Accept restyou agree
button,
to us doing so.
requirements, alcohol restrictions, and other
off-duty mandates.
HFACS Level 3: Unsafe Supervision
The Unsafe Supervision level is divided into
four categories.
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Inadequate Supervision: The role of any
supervisor is to provide their staff with the
opportunity to succeed, and they must
provide guidance, training, leadership,
oversight, or incentives to ensure the task is
performed safely and efficiently.
Plan Inappropriate Operation: Refers to
those operations that can be acceptable and
different during emergencies, but
unacceptable during normal operation (e.g.,
risk management, crew pairing, operational
tempo).We use cookies on this site to
enhance your user experience
Fail to Correct Known Problem: Refers to
By clicking the Accept button, you agree
those instances when deficiencies are known
to us doing so.
to the supervisor, yet are allowed to continue
unabated (e.g, report unsafe tendencies,
initiate corrective action, correct a safety
hazard).
Supervisory Violation: Refers to those
instances when existing rules and regulations
are willfully disregarded by supervisors (e.g.,
enforcement of rules and regulations,
authorized unnecessary hazard, inadequate
documentation).
HFACS Level 4: Organisational
Influences
The Organisational Influences level is divided
into three categories.
KCABDEEF
Resource Management: Refers to the
organisational-level decision-making
regarding the allocation and maintenance of
organisational assets (e.g.,
We use cookies human
on this site toresources,
enhance your
monetary/budget user experience
resources,
By clicking therecourse).
equipment/facility Accept button, you agree
to us doing so.
Organisational Climate: Refers to the working
atmosphere within the organisation (e.g.,
structure, policies, culture).
Operational Process: Refers to organisational
decisions and rules that govern the everyday
activities within an organisation (e.g.,
operations, procedures, oversight).
Related Articles
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Human Factors Analysis and Classification
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ICAO SHELL Model
James Reason HF Model
LMQ HF Model
PEAR Model
Further Reading
Human Factors Analysis and Classification
System (HFACS), version 8.0, 2022
Scott A. Shappell (Feb 2000), “The Human
Factors Analysis and Classification System–
HFACS” DOT/FAA/AM-00/7.
"The Human Factors Analysis and
We use cookies on this site to
Classification
enhanceSystem (HFACS),"
your user Approach,
experience
July - By
August 2004.
clicking the Accept button, you agree
to us doing so.
Human Factors Analysis and Classification
System–Maintenance Extension (HFACS-ME)
Review of Select NTSB Maintenance Mishaps:
An Update by John K. Schmidt, Don Lawson
and Robert Figlock. Aeromedical Division,
Naval Safety Center, and School of Aviation
Safety, Naval Postgraduate School, U.S. Navy,
2003.
Reason, J.(1990) “Human Error”. Cambridge
University Press
Ford, C., Jack, T., Crisp, V., & Sandusky, R.
(1999).”Aviation accident causal analysis.
Advances” Aviation Safety Conference
Proceedings, (P-343).
Shappell, S. and Wiegmann, D. (2001).
“Applying Reason: The human factors
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analysis and classification system”. Human
Factors and Aerospace Safety, 1, 59-86.
HFACS Analysis of Military and Civilian
Aviation Accidents: A North American
Comparison.ISASI,2004
Wiegmann, D. A., & Shappell, S. A. (2003). A
human error approach to aviation accident
analysis: The human factors analysis and
classification system. Burlington, VT: Ashgate
Publishing, Ltd.
DOT/FAA/AM-00/7 "The Human Factors
Analysis and Classification System - HFACS" -
FAA We use cookies on this site to
Shappell, S., Detwiler,
enhance your userC., experience
Holcomb, K.,
Boquet, A., Wiegmann,
By clicking the AcceptD., youHuman
(2006).
button, agree
Error and
to us Commercial
doing so. Aviation Accidents: A
Comprehensive, Fine-Grained Analysis Using
HFACS.
Categories:
Organisation and Human Performance,
Human Performance Modelling
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