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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 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

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

Drawing upon Reason’s (1990) concept of latent and active failures, HFACS describes four levels of failure: 1) Unsafe Acts, 2) Preconditions for Unsafe Acts, 3) Unsafe Supervision, and 4) Organizational Influences. A brief description of the major components and causal categories follows, beginning with the level most closely tied to the accident, i.e. unsafe acts.

3. Unsafe Supervision

Recall that in addition to those causal factors associated with the pilot/operator, Reason (1990) traced the causal chain of events back up the supervisory chain of command. As such, we have identified four categories of unsafe supervision: inadequate supervision, planned inappropriate operations, failure to correct a known problem, and supervisory violations (Figure 4). Each is described briefly below.

Figure 4. Categories of unsafe supervision.

Inadequate Supervision.

The role of any supervisor is to provide the opportunity to succeed. To do this, the supervisor, no matter at what level of operation, must provide guidance, training opportunities, leadership, and motivation, as well as the proper role model to be emulated. Unfortunately, this is not always the case.

For example, it is not difficult to conceive of a situation where adequate crew resource management training was either not provided, or the opportunity to attend such training was not afforded to a particular aircrew member. Conceivably, aircrew coordination skills would be compromised and if the aircraft were put into an adverse situation (an emergency for instance), the risk of an error being committed would be exacerbated and the potential for an accident would increase markedly.

In a similar vein, sound professional guidance and oversight is an essential ingredient of any successful organization. While empowering individuals to make decisions and function independently is certainly essential, this does not divorce the supervisor from accountability. The lack of guidance and oversight has proven to be the breeding ground for many of the violations that have crept into the cockpit. As such, any thorough investigation of accident causal factors must consider the role supervision plays (i.e., whether the supervision was inappropriate or did not occur at all) in the genesis of human error (Table 3).

TABLE 3. Selected examples of Unsafe Supervision (Note: This is not a complete listing)

Inadequate Supervision

  • Failed to provide guidance
  • Failed to provide operational doctrine
  • Failed to provide oversight
  • Failed to provide training
  • Failed to track qualifications
  • Failed to track performance

Planned Inappropriate Operations

  • Failed to provide correct data
  • Failed to provide adequate brief time
  • Improper manning
  • Mission not in accordance with rules/regulations
  • Provided inadequate opportunity for crew rest

Failed to Correct a Known Problem

  • Failed to correct document in error
  • Failed to identify an at-risk aviator
  • Failed to initiate corrective action
  • Failed to report unsafe tendencies

Supervisory Violations

  • Authorized unnecessary hazard
  • Failed to enforce rules and regulations
  • Authorized unqualified crew for flight

Planned Inappropriate Operations.

Occasionally, the operational tempo and/or the scheduling of aircrew is such that individuals are put at unacceptable risk, crew rest is jeopardized, and ultimately performance is adversely affected. Such operations, though arguably unavoidable during emergencies, are unacceptable during normal operations. Therefore, the second category of unsafe supervision, planned inappropriate operations, was created to account for these failures (Table 3).

Take, for example, the issue of improper crew pairing. It is well known that when very senior, dictatorial captains are paired with very junior, weak co-pilots, communication and coordination problems are likely to occur. Commonly referred to as the trans-cockpit authority gradient, such conditions likely contributed to the tragic crash of a commercial airliner into the Potomac River outside of Washington, DC, in January of 1982 (NTSB, 1982). In that accident, the captain of the aircraft repeatedly rebuffed the first officer when the latter indicated that the engine instruments did not appear normal. Undaunted, the captain continued a fatal takeoff in icing conditions with less than adequate takeoff thrust. The aircraft stalled and plummeted into the icy river, killing the crew and many of the passengers.

Clearly, the captain and crew were held accountable. They died in the accident and cannot shed light on causation; but, what was the role of the supervisory chain? Perhaps crew pairing was equally responsible. Although not specifically addressed in the report, such issues are clearly worth exploring in many accidents. In fact, in that particular accident, several other training and manning issues were identified.

Failure to Correct a Known Problem.

The third category of known unsafe supervision, Failed to Correct a Known Problem, refers to those instances when deficiencies among individuals, equipment, training or other related safety areas are “known” to the supervisor, yet are allowed to continue unabated (Table 3). For example, it is not uncommon for accident investigators to interview the pilot’s friends, colleagues, and supervisors after a fatal crash only to find out that they “knew it would happen to him some day.” If the supervisor knew that a pilot was incapable of flying safely, and allowed the flight anyway, he clearly did the pilot no favors. The failure to correct the behavior, either through remedial training or, if necessary, removal from flight status, essentially signed the pilot’s death warrant - not to mention that of others who may have been on board.

Likewise, the failure to consistently correct or discipline inappropriate behavior certainly fosters an unsafe atmosphere and promotes the violation of rules. Aviation history is rich with by reports of aviators who tell hair-raising stories of their exploits and barnstorming low-level flights (the infamous “been there, done that”). While entertaining to some, they often serve to promulgate a perception of tolerance and “one-up-manship” until one day someone ties the low altitude flight record of ground-level! Indeed, the failure to report these unsafe tendencies and initiate corrective actions is yet another example of the failure to correct known problems.

Supervisory Violations.

Supervisory violations, on the other hand, are reserved for those instances when existing rules and regulations are willfully disregarded by supervisors (Table 3). Although arguably rare, supervisors have been known occasionally to violate the rules and doctrine when managing their assets. For instance, there have been occasions when individuals were permitted to operate an aircraft without current qualifications or license. Likewise, it can be argued that failing to enforce existing rules and regulations or flaunting authority are also violations at the supervisory level. While rare and possibly difficult to cull out, such practices are a flagrant violation of the rules and invariably set the stage for the tragic sequence of events that predictably follow.

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