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Swiss Cheese Model

swiss cheese slice

The Human Factors Analysis and Classification System—HFACS

Cover and Documentation
1. Unsafe Acts
2. Preconditions for Unsafe Acts
3. Unsafe Supervision
4. Organizational Influences

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

Years Prior
April 25th
Fire Narrative
Lessons Learned

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 site also includes an animated illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."


It is our belief that the Human Factors Analysis and Classification System (HFACS) framework bridges the gap between theory and practice by providing investigators with a comprehensive, user-friendly tool for identifying and classifying the human causes of aviation accidents. The system, which is based upon Reason’s (1990) model of latent and active failures (Shappell & Wiegmann, 1997a), encompasses all aspects of human error, including the conditions of operators and organizational failure. Still, HFACS and any other framework only contributes to an already burgeoning list of human error taxonomies if it does not prove useful in the operational setting. In these regards, HFACS has recently been employed by the U.S. Navy, Marine Corps, Army, Air Force, and Coast Guard for use in aviation accident investigation and analysis. To date, HFACS has been applied to the analysis of human factors data from approximately 1,000 military aviation accidents. Throughout this process, the reliability and content validity of HFACS has been repeatedly tested and demonstrated (Shappell & Wiegmann, 1997c).

Given that accident databases can be reliably analyzed using HFACS, the next logical question is whether anything unique will be identified. Early indications within the military suggest that the HFACS framework has been instrumental in the identification and analysis of global human factors safety issues (e.g., trends in aircrew proficiency; Shappell, et al., 1999), specific accident types (e.g., controlled flight into terrain, CFIT; Shappell & Wiegmann, 1997b), and human factors problems such as CRM failures (Wiegmann & Shappell, 1999). Consequently, the systematic application of HFACS to the analysis of human factors accident data has afforded the U.S. Navy/Marine Corps (for which the original taxonomy was developed) the ability to develop objective, data-driven intervention strategies. In a sense, HFACS has illuminated those areas ripe for intervention rather than relying on individual research interests not necessarily tied to saving lives or preventing aircraft losses.

Additionally, the HFACS framework and the insights gleaned from database analyses have been used to develop innovative accident investigation methods that have enhanced both the quantity and quality of the human factors information gathered during accident investigations. However, not only are safety professionals better suited to examine human error in the field but, using HFACS, they can now track those areas (the holes in the cheese) responsible for the accidents as well. Only now is it possible to track the success or failure of specific intervention programs designed to reduce specific types of human error and subsequent aviation accidents. In so doing, research investments and safety programs can be either readjusted or reinforced to meet the changing needs of aviation safety.

Recently, these accident analysis and investigative techniques, developed and proven in the military, have been applied to the analysis and investigation of U.S. civil aviation accidents (Shappell & Wiegmann,1999). Specifically, the HFACS framework is currently being used to systematically analyze both commercial and General Aviation accident data to explore the underlying human factors problems associated with these events. The framework is also being employed to develop improved methods and techniques for investigating human factors issues during actual civil aviation accident investigations by Federal Aviation Administration and National Transportation Safety Board officials. Initial results of this project have begun to highlight human factors areas in need of further safety research. In addition, like their military counterparts, it is anticipated that HFACS will provide the fundamental information and tools needed to develop a more effective and accessible human factors accident database for civil aviation.

In summary, the development of the HFACS framework has proven to be a valuable first step in the establishment of a larger military and civil aviation safety program. The ultimate goal of this, and any other, safety program is to reduce the aviation accident rate through systematic, data-driven investment

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