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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."

The Human Factors Analysis and Classification System–HFACS

The “Swiss cheese” model
of accident causation
February 2000

Office of Aviation Medicine
Washington, DC 20591

The Human Factors
Analysis and Classification

Scott A. Shappell
FAA Civil Aeromedical Institute
Oklahoma City, OK 73125

Douglas A. Wiegmann
University of Illinois at Urbana-Champaign
Institute of Aviation
Savoy, IL 61874


February 2000


Final Report


This document is available to the public
through the National Technical Information
Service, Springfield, Virginia 22161.

U.S. Department
of Transportation

Federal Aviation


This document is disseminated under the sponsorship of the U.S. Department of Transportation in the interest of information exchange. The United States Government assumes no liability for the contents thereof.


Technical Report Documentation Page
1. Report No.
2. Government Accession No. 3. Recipient's Catalog No.
4. Title and Subtitle
The Human Factors Analysis and Classification System—HFACS

5. Report Date
February 2000
6. Performing Organization Code

7. Author(s)
Shappell, S.A. 1, and Wiegmann, D.A. 2
8. Performing Organization Report No.
9. Performing Organization Name and Address
1 FAA Civil Aeromedical Institute, Oklahoma City, OK 73125
2 University of Illinois at Urbana-Champaign, Institute of Aviation, Savoy, Ill. 61874

10. Work Unit No. (TRAIS)

11. Contract or Grant No.


12. Sponsoring Agency name and Address
Office of Aviation Medicine
Federal Aviation Administration
800 Independence Ave., S.W.
Washington, DC 20591

13. Type of Report and Period Covered

14. Sponsoring Agency Code

15. Supplemental Notes
This work was performed under task # AAM-A –00-HRR-520
16. Abstract
Human error has been implicated in 70 to 80% of all civil and military aviation accidents. Yet, most accident reporting systems are not designed around any theoretical framework of human error. As a result, most accident databases are not conducive to a traditional human error analysis, making the identification of intervention strategies onerous. What is required is a general human error framework around which new investigative methods can be designed and existing accident databases restructured. Indeed, a comprehensive human factors analysis and classification system (HFACS) has recently been developed to meet those needs. Specifically, the HFACS framework has been used within the military, commercial, and general aviation sectors to systematically examine underlying human causal factors and to improve aviation accident investigations. This paper describes the development and theoretical underpinnings of HFACS in the hope that it will help safety professionals reduce the aviation accident rate through systematic, data-driven investment strategies and objective evaluation of intervention programs
17. Key Words
Aviation, Human Error, Accident Investigation, Database Analysis
18. Distribution Statement
Document is available to the public through the National Technical Information Service, Springfield, Virginia 22161
19. Security Classif. (of this report)
20. Security Classif. (of this page)
21. No. of Pages     22. Price

  Form DOT F 1700.7 (872)           Reproduction of completed page authorized

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