The Human Factors Analysis and Classification System—HFACS
HFACS and Wildland Firefighting Investigations
Hugh Carson wrote this article a few days after the Cramer Fire
A Roadmap to a Just Culture: Enhancing the Safety Environment
Rainbow Springs Fire, 1984 — Incident Commander Narration
U.S. Forest Service Fire Suppression: Foundational Doctrine
Tools to Identify Lessons Learned
An FAA website presents 3
tools to identify lessons learned from accidents.
The “Swiss cheese” model
Planned Inappropriate Operations
Failed to Correct a Known Problem
Occasionally, the operational tempo and/or the scheduling of aircrew is such that individuals are put at unacceptable risk, crew rest is jeopardized, and ultimately performance is adversely affected. Such operations, though arguably unavoidable during emergencies, are unacceptable during normal operations. Therefore, the second category of unsafe supervision, planned inappropriate operations, was created to account for these failures (Table 3).
Take, for example, the issue of improper crew pairing. It is well known that when very senior, dictatorial captains are paired with very junior, weak co-pilots, communication and coordination problems are likely to occur. Commonly referred to as the trans-cockpit authority gradient, such conditions likely contributed to the tragic crash of a commercial airliner into the Potomac River outside of Washington, DC, in January of 1982 (NTSB, 1982). In that accident, the captain of the aircraft repeatedly rebuffed the first officer when the latter indicated that the engine instruments did not appear normal. Undaunted, the captain continued a fatal takeoff in icing conditions with less than adequate takeoff thrust. The aircraft stalled and plummeted into the icy river, killing the crew and many of the passengers.
Clearly, the captain and crew were held accountable. They died in the accident and cannot shed light on causation; but, what was the role of the supervisory chain? Perhaps crew pairing was equally responsible. Although not specifically addressed in the report, such issues are clearly worth exploring in many accidents. In fact, in that particular accident, several other training and manning issues were identified.
The third category of known unsafe supervision, Failed to Correct a Known Problem, refers to those instances when deficiencies among individuals, equipment, training or other related safety areas are “known” to the supervisor, yet are allowed to continue unabated (Table 3). For example, it is not uncommon for accident investigators to interview the pilot’s friends, colleagues, and supervisors after a fatal crash only to find out that they “knew it would happen to him some day.” If the supervisor knew that a pilot was incapable of flying safely, and allowed the flight anyway, he clearly did the pilot no favors. The failure to correct the behavior, either through remedial training or, if necessary, removal from flight status, essentially signed the pilot’s death warrant - not to mention that of others who may have been on board.
Likewise, the failure to consistently correct or discipline inappropriate behavior certainly fosters an unsafe atmosphere and promotes the violation of rules. Aviation history is rich with by reports of aviators who tell hair-raising stories of their exploits and barnstorming low-level flights (the infamous “been there, done that”). While entertaining to some, they often serve to promulgate a perception of tolerance and “one-up-manship” until one day someone ties the low altitude flight record of ground-level! Indeed, the failure to report these unsafe tendencies and initiate corrective actions is yet another example of the failure to correct known problems.
Supervisory violations, on the other hand, are reserved for those instances when existing rules and regulations are willfully disregarded by supervisors (Table 3). Although arguably rare, supervisors have been known occasionally to violate the rules and doctrine when managing their assets. For instance, there have been occasions when individuals were permitted to operate an aircraft without current qualifications or license. Likewise, it can be argued that failing to enforce existing rules and regulations or flaunting authority are also violations at the supervisory level. While rare and possibly difficult to cull out, such practices are a flagrant violation of the rules and invariably set the stage for the tragic sequence of events that predictably follow.
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