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
Foreword
The term ‘no-blame culture’ flourished in the 1990s and still
endures today. Compared to the largely punitive cultures that it sought
to replace, it was clearly a step in the right direction. It acknowledged
that a large proportion of unsafe acts were ‘honest errors’(the
kinds of slips, lapses and mistakes that even the best people can make)
and were not truly blameworthy, nor was there much in the way of remedial
or preventative benefit to be had by punishing their perpetrators. But
the ‘no-blame’ concept had two serious weaknesses. First, it
ignored—or, at least, failed to confront—those individuals
who willfully (and often repeatedly) engaged in dangerous behaviors that
most observers would recognize as being likely to increase the risk of
a bad outcome. Second, it did not properly address the crucial business
of distinguishing between culpable and non-culpable unsafe acts.
In my view, a safety culture depends critically upon first negotiating
where the line should be drawn between unacceptable behavior and blameless
unsafe acts. There will always be a grey area between these two extremes
where the issue has to be decided on a case by case basis. This is where
the guide-lines provided by A Roadmap to a Just Culture will be of great
value. A number of aviation organizations have embarked upon this process,
and the general indications are that only around 10 per cent of actions
contributing to bad events are judged as culpable. In principle, at least,
this means that the large majority of unsafe acts can be reported without
fear of sanction. Once this crucial trust has been established, the organization
begins to have a reporting culture, something that provides the system
with an accessible memory, which, in turn, is the essential underpinning
to a learning culture. There will, of course, be setbacks along the way.
But engineering a just culture is the all-important early step; so much
else depends upon it.
James Reason
<<< continue
reading—A Roadmap to a Just Culture, Executive Summary >>>
Reprinted by permission from the Global Aviation Information Network.
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