The Human Factors Analysis and Classification System—HFACS
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
Rainbow Springs Fire, 1984 — Incident Commander Narration
U.S. Forest Service Fire Suppression: Foundational Doctrine
Tools to Identify Lessons Learned
The “Swiss cheese” model
Resource / Aquisition Management
Excessive cost-cutting could also result in reduced funding for new equipment or may lead to the purchase of equipment that is sub optimal and inadequately designed for the type of operations flown by the company. Other trickle-down effects include poorly maintained equipment and workspaces, and the failure to correct known design flaws in existing equipment. The result is a scenario involving unseasoned, less-skilled pilots flying old and poorly maintained aircraft under the least desirable conditions and schedules. The ramifications for aviation safety are not hard to imagine.
Organizational Climate refers to a broad class of organizational variables that influence worker performance. Formally, it was defined as the “situationally based consistencies in the organization’s treatment of individuals” (Jones, 1988). In general, however, organizational climate can be viewed as the working atmosphere within the organization. One telltale sign of an organization’s climate is its structure, as reflected in the chain-of-command, delegation of authority and responsibility, communication channels, and formal accountability for actions (Table 4). Just like in the cockpit, communication and coordination are vital within an organization. If management and staff within an organization are not communicating, or if no one knows who is in charge, organizational safety clearly suffers and accidents do happen (Muchinsky, 1997).
An organization’s policies and culture are also good indicators of its climate. Policies are official guidelines that direct management’s decisions about such things as hiring and firing, promotion, retention, raises, sick leave, drugs and alcohol, overtime, accident investigations, and the use of safety equipment. Culture, on the other hand, refers to the unofficial or unspoken rules, values, attitudes, beliefs, and customs of an organization. Culture is “the way things really get done around here.”
When policies are ill-defined, adversarial, or conflicting, or when they are supplanted by unofficial rules and values, confusion abounds within the organization. Indeed, there are some corporate managers who are quick to give “lip service” to official safety policies while in a public forum, but then overlook such policies when operating behind the scenes. However, the Third Law of Thermodynamics tells us that, “order and harmony cannot be produced by such chaos and disharmony”. Safety is bound to suffer under such conditions.
This category refers to corporate decisions and rules that govern the everyday activities within an organization, including the establishment and use of standardized operating procedures and formal methods for maintaining checks and balances (oversight) between the workforce and management. For example, such factors as operational tempo, time pressures, incentive systems, and work schedules are all factors that can adversely affect safety (Table 4). As stated earlier, there may be instances when those within the upper echelon of an organization determine that it is necessary to increase the operational tempo to a point that overextends a supervisor’s staffing capabilities. Therefore, a supervisor may resort to the use of inadequate scheduling procedures that jeopardize crew rest and produce sub optimal crew pairings, putting aircrew at an increased risk of a mishap. However, organizations should have official procedures in place to address such contingencies as well as oversight programs to monitor such risks.
Regrettably, not all organizations have these procedures nor do they engage in an active process of monitoring aircrew errors and human factor problems via anonymous reporting systems and safety audits. As such, supervisors and managers are often unaware of the problems before an accident occurs. Indeed, it has been said that “an accident is one incident to many” (Reinhart, 1996). It is incumbent upon any organization to fervently seek out the “holes in the cheese” and plug them up, before they create a window of opportunity for catastrophe to strike.
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