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 Firefighting Investigations

Hugh Carson wrote this article a few days after the Cramer Fire

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

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

References

Bird, F. (1974). Management guide to loss control. Atlanta, GA: Institute Press.

Heinrich, H.W., Petersen, D., & Roos, N. (1980). Industrial accident prevention: A safety management approach (5th ed.). New York: McGraw-Hill.

Helmreich, R.L., & Foushee, H.C. (1993). Why crew resource management? Empirical and theoretical bases of human factors training in aviation. In E.L. Wiener, B.G. Kanki, & R.L. Helmreich(Eds.), Cockpit resource management (pp. 3-45). San Diego, CA: Academic Press.

Jones, A.P. (1988). Climate and measurement of consensus:
A discussion of “organizational climate.” In S.G. Cole, R.G. Demaree & W. Curtis, (Eds.), Applications of Interactionist Psychology: Essays in Honor of Saul B. Sells (pp. 283-90). Hillsdale, NJ: Earlbaum.

Murray, S.R. (1997). Deliberate decision making by aircraft pilots: A simple reminder to avoid decision making under panic. The International Journal of Aviation Psychology, 7, 83-100.

Muchinsky, P.M. (1997). Psychology applied to work (5th ed.). Pacific Grove, CA: Brooks/Cole Publishing Co.

National Transportation Safety Board. (1982). Air Florida, Inc., Boeing 737-222, N62AF, Collision with 14th Street bridge, near Washington National Airport, Washington, D.C., January 13, 1982 (Tech. Report NTSB-AAR-82-8). Washington: National Transportation Safety Board.

Orasanu, J.M. (1993). Decision-making in the cockpit. In E.L. Wiener, B.G. Kanki, and R.L. Helmreich (Eds.), Cockpit resource management (pp. 137-72). San Diego, CA: Academic Press.

Rasmussen, J. (1982). Human errors: A taxonomy for describing human malfunction in industrial installations. Journal of Occupational Accidents, 4, 311-33.

Reason, J. (1990). Human error. New York: Cambridge University Press.

Reinhart, R.O. (1996). Basic flight physiology (2nd ed.). New York: McGraw-Hill.

Senders, J.W., and Moray, N.P. (1991). Human error: Cause, prediction and reduction. Hillsdale, NJ: Earlbaum.

Shappell, S.A., and Wiegmann, D.A. (1996). U.S. naval aviation mishaps 1977-92: Differences between single- and dual-piloted aircraft. Aviation, Space, and Environmental Medicine, 67, 65-9.

Shappell, S.A. and Wiegmann D.A. (1997a). A human error approach to accident investigation: The taxonomy of unsafe operations. The International Journal of Aviation Psychology, 7, 269-91.

Shappell, S.A. & Wiegmann, D.A. (1997b). Why would an experienced aviator fly a perfectly good aircraft into the ground? In Proceedings of the Ninth International Symposium on Aviation Psychology, (pp. 26-32). Columbus, OH: The Ohio State University.

Shappell, S.A. and Wiegmann, D.A. (1997). A reliability analysis of the Taxonomy of Unsafe Operations. Aviation, Space, and Environmental Medicine, 68, 620.

Shappell, S.A. and Wiegmann, D.A. (1999a). Human error in commercial and corporate aviation: An analysis of FAR Part 121 and 135 mishaps using HFACS. Aviation, Space, and Environmental Medicine, 70, 407.

Shappell, S., Wiegmann, D., Fraser, J., Gregory, G., Kinsey, P., and Squier, H (1999b). Beyond mishap rates: A human factors analysis of U.S. Navy/ Marine Corps TACAIR and rotary wing mishaps using HFACS. Aviation, Space, and Environmental Medicine, 70, 416-17.

Wiegmann, D.A. and Shappell, S.A. (1997). Human factors analysis of post-accident data: Applying theoretical taxonomies of human error. The International Journal of Aviation Psychology, 7, 67-81.

Wiegmann, D.A. and Shappell, S.A. (1999). Human error and crew resource management failures in Naval aviation mishaps: A review of U.S. Naval Safety Center data, 1990-96. Aviation, Space, and Environmental Medicine, 70, 1147-51.