The Human Factors Analysis and Classification System—HFACS Cover
and Documentation
Introduction
1. Unsafe Acts
2. Preconditions
for Unsafe Acts
3. Unsafe Supervision
4. Organizational
Influences
Conclusion
References
HFACS and Wildland Fatality Investigations
Hugh Carson wrote this
article a few days after the Cramer Fire
Bill Gabbert wrote this article following the release of the Yarnell Hill Fire ADOSH report
A Roadmap to a Just Culture:
Enhancing the Safety Environment
Cover
and Contents
Forward by James Reason
Executive Summary
1. Introduction
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
5. References
Appendix A. Reporting Systems
Appendix B. Constraints to a Just Reporting Culture
Appendix C. Different Perspectives
Appendix D. Glossary of Acronyms
Appendix E. Report Feedback Form
Rainbow Springs Fire, 1984 — Incident Commander Narration
Introduction
Years Prior
April 25th
Fire Narrative
Lessons Learned
Conclusion
Tools to Identify Lessons Learned
An FAA website presents 3
tools to identify lessons learned from accidents. The site also
includes an animated
illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."
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A Roadmap to a Just Culture:
Enhancing the Safety Environment
Prepared by: GAIN Working Group E,
Flight Ops/ATC Ops Safety Information Sharing
First Edition • September 2004
Appendix E. Report Feedback Form
Please submit this form to:
GAIN Working Group E
c/o RS Information Systems, Inc.
1651 Old Meadow Road
McLean, Virginia 22102 USA
Fax: +1 (202) 267-5234; Email: WGE@gainweb.org
Name: ________________________________________________________________
Title/Position: ___________________________________________________________
Organization:____________________________________________________________
Mailing Address:_________________________________________________________
Phone:_________________Fax:____________________E-Mail:: __________________
1. How useful is this report to your organization? (Please circle one)
not
useful - 1 2 3 4 5 - very useful
2. Do you plan to use this report to help implement a “Just Culture” in
your organization? If so, what information will be most helpful to you?
3.
What information would you like to see added to this report?
4. What
activities should WG E undertake that would be most useful to your organization?
5. Would you or someone in your organization be interested in participating
in WG E?
YES / NO
6. Would you like to be added to our mailing list?
YES / NO
7. Other Comments/Suggestions
Reprinted by permission from the Global Aviation Information Network.
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