Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Developing HFACS
Developing the Human Factor Analysis Classification System for the Fire Service
Ryan M. Cole
Skyland Fire Rescue Skyland, NC
Developing HFACS 2
Certification Statement I herby certify that this paper constitutes my own product, that where the language of others is
set forth, quotation marks so indicate, and that appropriate credit is given where I have used the
language, ideas, expressions or writing of another.
Signed:___________________________________
Developing HFACS 3
Abstract
The methodology of the research was based on developing a proven accident analysis
tool to identify specific, measurable, preventable causal factors affecting the fire service. The
Human Factor Analysis Classification System provides a supplement to incident and injury
investigation providing insight into human error. Unsafe acts, pre-conditions to unsafe acts,
unsafe supervision, and organizational issues are the primary areas of the Human Factor Analysis
Classification System, which provides causal factors in each area.
The causal factors identify the hazards of each area resulting in the incident occurring
which if identified could be prevented. The Human Factor Analysis Classification tool will
identify the specific data which can result in clear, concise, specific, and measurable objectives,
as it has for other industries.
Developing HFACS 4
Table of Contents
Abstract……………………………………………………………………………………………3
Table of Contents………………………………………………………………………………….4
Introduction………………………………………………………………………………………..5
Background and Significance……………………………………………………………………..6
Literature Review…………………………………………….…………………………………..11
Procedures………………………………………………….…………………………………….36
Results……………………………………………………………………………………………38
Discussion………………………………………………………………………………………..50
Recommendations………………………………………………………………………………..53
Reference List……………………………………………………………………………………57
Appendix
Appendix A (Swiss Cheese Model)..……………………………………………………………61
Appendix B (HFACS Flow Chart)………………………………………………………………62
Developing HFACS 5
Introduction
Preventing firefighter injuries and fatalities has proven to be difficult while looking at the
trends without any noticeable declines. The fire service focus on safety is more prevalent now
than any other time in history (Brunacini, 2008). Injury and fatality information is abundant with
causal factors identified in broad terminology. As identified in Firefighter Fatalities in the United
States 2007 by the National Fire Protection Association (NFPA) (2008) provides a vision of what
the natures of fatalities are such as: sudden cardiac death, burns, asphyxiation, and internal
trauma. Deaths by causes of injury are identified as: exertion or stress, struck by or contact with
object, caught or trapped, and falls (NFPA, 2008). To teach prevention, the behavior must first
be identified then it is essential that the behavior is modified or changed. The difficulty in
identifying the behaviors in the broad causes stated is evident. The identification of behaviors
must be specific and measurable to create changeable effects. Identifying specific and
measurable behaviors is utilized widely in public education; however, firefighter safety is not as
prevalent. The Human Factor Analysis Classification System (HFACS) developed by Wiegman
and Shappell (2003) was identified in previous research: Identifying a Risk Evaluation Tool to
Prevent Injuries and Fatalities by Cole (2007) as the most appropriate human error accident
evaluation tool. The HFACS identifies causal factors in unsafe acts of the individual,
preconditions of unsafe acts, unsafe supervision, and organizational influences. The HFACS
system has been developed and utilized by many industries, primarily aviation; however, it has
not been specified for the fire service. The HFACS provides categories, subcategories and causal
factors from the four primary divisions identified.
Developing HFACS 6
The previous research provided the basis for the current project to identify the necessary
changes of a proven investigation program (HFACS) utilized by the military, transportation and
aviation industry to meet the needs of the fire service. To facilitate the necessary changes the
following areas were identified as needing to be addressed:
1. What are the categories and causal factors of unsafe acts, preconditions for unsafe acts,
supervisory issues and organizational issues in the Human Factors Analysis Classification
System that affect the fire service?
2. How are uses of the Human Factor Analysis Classification System in other industries
classified and relative to the fire service?
3. How would the Human Factor Analysis Classification System be utilized to provide injury
prevention data in the fire service?
4. What advantages would the Human Factor Analysis Classification provide in the analysis of
firefighter injuries, and fatalities?
In answering the research questions, the current HFACS program will be further
evaluated to identify needs of the fire service, as well as contributory documents further
classifying the divisions, categories, subcategories, and causal factors affecting the fire service. If
successful the research will provide a path to specific measurable behaviors that can be identified
as preventable changes.
Background and Significance
Skyland Fire and Rescue currently does not utilize an accident analysis program when an
incident occurs that causes injury or property damage. Skyland as many other organizations,
conducts a formal investigation of every incident. The formal investigation identifies how the
operator failed and what the organization can do to prevent it from occurring in the future. With
Developing HFACS 7
an average of nearly six injuries per year, a total of 57injuries in a ten year period, and over a
half a million dollars in property damage, it was determined to seek a program to analyze the
cause of injuries and damage. In a previous research project Identifying a Risk Evaluation Tool
to Prevent Injuries and Fatalities (Cole 2007), the analysis tool identified to obtain the best
information providing changeable behaviors was the Human Factors Analysis Classification
System.
In North Carolina when an in line of duty death occurs, the Office of State Fire Marshal
(NCOSFM) provides assistance to families and organizations of the fallen firefighter. One of the
areas of assistance provided by NCOSFM includes collecting documentation of the incident and
providing appropriate information to federal and state officials to ensure receipt of the Public
Safety Officer Benefit. Through the collection of information NCOSFM has the most
comprehensive documentation of firefighter fatalities in North Carolina. North Carolina
experienced 57 firefighter fatalities in a ten year period from 1998 to 2008. The types of
incidents resulting in fatalities included; heart attacks at 58%, motor vehicle crashes at 28%, fires
at 9%, and other types at 9%.
The United States Fire Administration (USFA) and National Fallen Firefighters
Foundation (NFFF) provided the summit which identified the 16 Firefighter Life Safety
Initiatives in 2004. Five of the life safety initiatives will be addressed in the following research:
enhance the personal and organizational accountability for health and safety throughout the fire
service, focus greater attention on the integration of risk management with incident management
at all levels, empower all firefighters to stop unsafe practices, utilize available technology
wherever it can produce higher levels of health and safety, and thoroughly investigate all
firefighter fatalities, injuries and near misses. (USFA & NFFF, 2004)
Developing HFACS 8
The National Fire Service Research Agenda Symposium (2005) a follow up from the
2004 Life Safety Summit identified that 100 firefighters were being killed annually with an
additional 100,000 injured in the line of duty. In an attempt to reduce injuries and fatalities, the
USFA adopted a goal of reducing fatalities by 25% in 5 years and 50% in 10 years. The
symposium was based on one of the 16 life safety initiatives which called for the development of
a national research agenda to support the implementation of advances in firefighter health and
safety. Identification of projects was made in the symposium on what efforts are currently being
made and which areas need attention on a priority basis regarding the life safety initiatives. Three
areas relative to accident analysis investigation were identified as having the highest priority
with the most critical urgency. The symposium classified each issue by identifying the need,
background and comments from participants which are listed below:
1. Issue: Analysis of Fire Service Culture
Need: Identify attitudes, beliefs and behaviors that contribute to high-risk behaviors
and resistance to changes that would improve health and safety. Also identify
effective motivators to promote positive changes.
Background: The current fire service culture is widely recognized as a barrier to
making important improvements in firefighter safety and health. Cultural values often
place bravado and heroism ahead of firefighter safety.
2. Issue: Identify Fire Ground Factors that Contribute to Fire Service Injuries and
Fatalities.
Need: The first phase of this project would be directed toward systematically
identifying and analyzing the factors that contribute to firefighter injuries and
fatalities. This would involve detailed analysis of individual cases that result in
Developing HFACS 9
injuries or fatalities, as well as “close call” situations. This would also include
statistical analysis of associated data at the local, regional, national and international
levels. The second phase of the project would be directed toward developing
mitigation strategies to address the critical risk factors and reduce injury and fatality
rates.
Background: The rate of firefighter injuries and fatalities occurring on the fire ground
is a critical concern. The research component of this effort would be directed toward
identifying critical factors that result in firefighter deaths and injuries. After these
factors are identified, effective mitigation efforts such as training programs can be
developed to address them.
3. Issue: Situational Awareness of Firefighter Physiological and Environmental
Conditions
Need: The ability to continuously monitor the location and physiological status of
firefighters who are working in hazardous areas is a critical life safety issue. The
ability to monitor external conditions within the firefighters’ work environment is
equally important, in order to identify imminent threats and changing conditions. The
information should be available to the firefighter and should also be transmitted to an
external command post, where it can be monitored and recorded.
Background: Each year, over a period of 15 years, an average of 11 firefighters had
died from asphyxiation or burns while performing interior structural firefighting
operations. Many of these fatalities occur in scenarios that involve factors of
disorientation, physical exhaustion, running out of air, and/or being overcome by
rapidly changing conditions while operating in a dangerous environment. The desired
Developing HFACS 10
solution would make the firefighter aware of dangerous situations and transmit the
data in real time so that it could be monitored and recorded outside the hazardous area.
4. Issue: Firefighter Fatalities and Injuries Involving Motor Vehicle Accidents
Need: Conduct a detailed analysis of firefighter fatalities and injuries resulting from
motor vehicle accidents in order to identify causal and contributing factors. The
analysis should include, but not be limited to: fire department vehicles, privately
owned vehicles responding to emergency incidents, vehicle age and design,
applicable design standards, vehicle inspection records, compliance with traffic laws
and response procedures, time of day and weather conditions, road surface, seat belt
usage, mechanism of injury, driver training and certification, and cause of accident.
Background: Detailed information on emergency vehicle accidents is often collected
for individual incidents; however it is not compiled or analyzed nationally. This
project would involve an effort to obtain and conduct extensive analysis of
emergency vehicle accident data (NFFF, 2005).
The United States Fire Administration (USFA) produced Fire-Related Firefighter Injuries
in 2004 (2008) which identified trends of fire ground injuries based primarily on the analysis of
the National Fire Incident Reporting System (NFIRS) fire incident data for 2004. From 1995
through 2004 firefighters injuries at fires have been double that of civilian injuries and accounted
for half of all firefighter injuries. Total firefighter injuries and fire ground injuries have
decreased throughout the 10 year period following the downward trend of fires. The percentage
of firefighter injuries per thousand fires from 1995 to 2004 has seen no noticeable decrease for
the ten years. This was an average of 24 injuries for every thousand fires (USFA 2008).
Developing HFACS 11
Literature Review
The United States Fire Administration (USFA) 2008 report Fire-Related Firefighter
Injuries in 2004, identified that incidents producing injury yielded single injuries most of the
time (82%) and just over half of the time (52%) did not result in lost work. The highest risk for
firefighter injury exists from age 20 to 39 with the leading cause of injuries relating to smoke
inhalation and exhaustion. Firefighters in the age group of 40 and above had a leading cause of
injuries relating to strains and sprains. The greatest cause of injury resulted in overexertion and
strains (16.4%) followed by exposure to fire and smoke (15.8%). More firefighters were injured
(38.4%) outside the structure than inside the structure (35%).
The general factors contributing to injuries were classified as:
Fire development 16.0%
Slippery or uneven surfaces 12.8%
Collapse or falling object 7.8%
Holes 1.8%
Vehicle or apparatus issue 1.7%
Lost, caught, trapped, or confined 1.4%
Hostile acts 0.5%
No Factor 13.4%
Other 12.0%
Unknown 32.8%
Developing HFACS 12
Physical condition prior to the highest severity injuries included:
Rested 72.4%
Fatigued 9.2%
Ill or injured 2.1%
Physical Condition 1.0%
Unspecified 15.4%
The type of activity which was being conducted at the time of injury of firefighters was
highest while extinguishing the fire or neutralizing the incident (41.0%) followed by suppression
support (20.2%). The contrast between firefighter fatalities and injuries is sharp with 79% of
fatalities resulting from heart attacks and internal trauma. Strains, wounds, and burns lead
injuries at 44% and heart attacks and internal trauma only account for 2% of injuries (USFA,
2008)
The National Institute of Standards and Technology (NIST) (2003) developed a study,
Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002. The study was developed
utilizing data obtained from National Institute for Occupational Safety and Health (NIOSH), the
National Fire Protection Association (NFPA), and the USFA National Fallen Firefighter
Memorial Database. From 1979-2002 firefighter fatalities from structural collapse accounted for
over 180 deaths not including the 2001 World Trade Center Incident. Just over half (63%) of the
deaths caused by structural collapse occurred from 1994 to 2002 for a total of 47 incidents. This
included eight of the last twenty-three years studied. Almost half of the deaths involved career
firefighters with six or more years of experience. The nature of deaths identified in structural
collapse included; asphyxiation, burns, internal trauma and other causes. Asphyxiation accounted
for 42% of the fatalities. In two previous NFPA studies 60% of the fatalities come from being
Developing HFACS 13
caught or trapped; 40% of the fatalities were struck or had contact with an object. From 1994 to
2002 the percentage rose to over 85% being caught or trapped. The report concludes that the
number of fatalities due to collapse has declined since 1979; however, the number of collapse
fatalities in residential structures has increased drastically. Collapse fatalities occur by
firefighters being caught or trapped in the structure or being struck by an object, and the study
has shown that the percentage of being caught or trapped has increased. The probable causes for
the trends were not determined due to the need for additional data. (NIST, 2003)
The International Association of Firefighters sponsored a research project by Moore-
Merrell, Zhou, McDonald-Valentine, Goldstein, and Slocum (2008) Contributing Factors to
Firefighter Line-Of-Duty Injury in Metropolitan Fire Departments in the United States
evaluating nine metropolitan fire departments. The group evaluated 3450 injuries with
dominating contributing factors leading to lack of situational awareness at 37.35%, lack of
wellness or fitness at 28.57% and human error at 10.65%. The premise of the research was based
on classifying the injuries into contributing factor clusters or contributing factors which occurred
together.
The first cluster included equipment failure, lack of training, structural failure, act of
violence, civilian error, horseplay and lack of teamwork. The second cluster included crew size,
lack of wellness or fitness, fatigue, and weather or act of nature. The third cluster included
protective equipment not worn and dangerous substance. The fourth and final cluster included
decision making, lack of communication, standard operating guideline or procedure breech,
protocol breech, human error, and lack of situational awareness. The fourth cluster was identified
as being responsible for more than 30% of all firefighter injuries while the second cluster was
Developing HFACS 14
responsible for 26.2% of the injuries over the two year period of 2005-2006 (Moore-Merrell, et
al, 2008).
With the broad classification of causal factors the clusters identified decision making,
lack of communication, standard operating guideline or procedure breech, protocol breech,
human error, lack of situational awareness, crew size, lack of wellness or fitness, fatigue, and
weather or act of nature as being responsible for 56.2% of the injuries. The second and fourth
clusters carried the highest percentage in all categories including age, years of service, scene type,
and type of duty. In the final discussion, Moore-Merrell et al. identified that the association
between factors within a cluster could not be identified and that they may act independently or
collectively (Moore-Merrell, et al, 2008)
The United States Naval Safety Center (NSC) (2006) produced The Navel Flight
Surgeon’s Pocket Reference to Aircraft Mishap Investigation Sixth Edition, which provides a
comprehensive standard for investigating naval aircraft incidents. As stated in the reference,
HFACS provides a proven template to aid the investigator in organizing the incident while
providing a detailed analysis of human error. Historical data provided that human error with
other factors or alone is present in approximately 80% of the aircraft mishaps. Causal factors are
defined as the factors which resulted in the incident occurring causing unnecessary injury or
damage. Most aircraft mishaps are the result of a combination of two or more causal factors, in
which one factor removed, would prevent the mishap from occurring. All causal factors are
considered to be “under human control”; therefore, all hazards can be eliminated and mishaps
prevented. Environmental conditions (weather) are not hazards, as the choice to perform in the
condition would be the hazard.
Developing HFACS 15
Mishaps for the NSC aircraft incidents are classified by severity with Class A through C
requiring an investigation:
1. Class A
Aircraft destroyed or missing, or
Property damage of $1,000,000 or greater, or
Fatality or permanent disability as a result of the mishap
2. Class B
Property damage between $200,000 to $1,000,000, or
Permanent or partial disability as a result of the mishap, or
Hospitalization of three or more personnel
3. Class C
Property damage of $20,000 to $200,000, or
An injury that results in 5 or more lost workdays
4. Hazard
Property damage of less than $20,000, and
There are no reportable injuries
The event is not a mishap it would be reported as a hazard
The NSC reference manual also includes a Risk Assessment Codes (RAC) matrix used to
identify severity and probability of the mishap reoccurring in the future. In the matrix hazard
severity is classified in Arabic numbers to determine hazard abatement priorities, as mishap
probability is identified as Alphabetic letters identified below:
Developing HFACS 16
Hazard Severity Category:
I. The hazard may cause death or loss of a facility or asset (Class A Damage).
II. May cause severe injury, severe occupational illness, significant property damage,
or severe degradation to assets (Class B Damage).
III. May cause minor injury, minor occupational illness, minor property damage, or
minor degradation to assets (Class C Damage).
IV. Would not significantly affect personnel safety or health, property or asset;
however, it is a violation of an established regulation or standard.
Mishap Probability:
A. Likely to occur immediately or in a short period of time (one or more times in the
next year).
B. Likely to occur in time (within the next 3 years).
C. Likely to occur several times during the life of the aircraft.
D. Unlikely to occur, but is feasible within the lifetime of the aircraft.
Mishap Probability Hazard
Severity A B C D
I 1 1 2 3
II 1 2 3 4
III 2 3 4 5
IV 3 4 5 5
Developing HFACS 17
RAC Definitions:
1. Critical Risk
2. Serious Risk
3. Moderate Risk
4. Minor Risk
5. Negligible Risk
The NSC reference identifies that human error has been identified in many arenas as the
cause of the accident occurring; however, stopping at human error is a naïve approach to mishap
causation. The goal of a mishap investigation is to identify and determine why the failures or
conditions led to the mishap and how it can be prevented in the future. Mishaps are rarely
attributed to a single cause or even a single individual. Mishaps are the result of a myriad of
latent and active failures. The reference defines active and latent failures by sighting James
Reason (1990) who developed the concept of human error with active and latent failures
inspiring Wiegmann and Shappell to develop HFACS. Active failures are the actions or inactions
of people who are believed to have cased the mishap. Latent failures are the errors that exist
within a crew, organization, supervision or preconditions which may have been previously
dormant. Reason’s (1990) Swiss Cheese model is also identified in the reference which provides
a simplistic depiction identifying that each failure is like a slice of Swiss cheese (defense barriers)
which has holes in it (failed or absent defenses) and as the holes align a mishap occurs. The
model has four levels (slices of cheese) as identified below:
Developing HFACS 18
1. Unsafe Acts – Active Failures
2. Preconditions for Unsafe Acts – Latent Failures or Conditions
3. Unsafe Supervision – Latent Failures or Conditions
4. Organizational Influences – Latent Failures or Conditions
(Appendix A)
Most investigations as stated in the reference stop at the unsafe acts level which identifies
the human involved in the error or the surface of the problem instead of identifying the latent
failures influencing the mishap. Without identification of the latent failures proper measures can
not be taken to prevent future incidents (NSC, 2006).
The “Swiss Cheese” model created by James Reason (1990) was developed to help
concept that as human error is the cause of most incidents the root cause usually lies deeper in
the organization. Douglas Wiegman and Scott Shappell (2003) built upon the model of Reason to
develop categories of each area of unsafe acts, preconditions, unsafe supervision, and
organizational influences. Wiegman and Shappell gained their experience at the NSC as human
factor psychologist, flight surgeon and Navy Commander. Unsafe acts are divided into two areas,
errors and violations. Errors are frequently the first to be identified since human beings by their
Developing HFACS 19
very nature make errors. As stated by Wiegmann and Shappell (2003) To err is human (Plutarch
100 AD). Violations are not as frequently recognized as they represent the willful disregard for
the rules.
Errors are broken down into three additional areas including; skill based errors, decision
errors, and perceptual errors. Skill based errors are those which are based on basic skills which
occur without significant thought. With skill based errors relying on attention and/or memory-
they are very vulnerable to failures. Some of the skill based errors which are associated with
attention failures include breakdown in visual scan patterns, task fixation, and miss-ordering
procedural steps. Memory failures being different than attention failures, include items such as
omitted checklist, losing place, or forgotten intentions. Skill based errors can also happen even
when no apparent attention of memory failure is present. Decision errors are the intentional
behaviors which are inappropriate or inadequate for the situation, often referred to as honest
mistakes. Perceptual errors exist when the individual’s perception of the world is different than
reality or when sensory inputs are disregarded which may be classified as visual illusions or
spatial disorientation (NSC, 2001).
Violations are separated by routine and exceptional violations. Routine violations are the
willful departure from authority that simply cannot be tolerated which tends to be routine or
habitual by nature or part of the individuals normal behavior. Exceptional violations are those
which appear as isolated departures from authority which are not necessarily part of the
individual’s behavior or condoned by management (NSC, 2006).
Developing HFACS 20
Unsafe acts provides the information on the individual performance which caused the
incident to occur which can also provide information on what caused the incident the majority of
the time. However, only identifying the unsafe acts is focusing on a symptom without identifying
the cause. The first form of identifying the deeper cause beyond the unsafe acts is to identify
preconditions to unsafe acts. The preconditions of unsafe acts are divided into two primary areas-
including; substandard conditions of operators, and substandard practices of operators (NSC,
2006)
Substandard conditions of operators are further subdivided into three additional
conditions - adverse mental states, adverse physiological states, and physical/mental limitations.
An adverse mental state takes into account those conditions which affect performance and the
individual’s mental preparedness for the task. Adverse physiological states include conditions
that preclude to the incident such as physical fatigue, hypoxia, or pharmacological and medical
treatments or conditions. Physical/mental limitations are identified as the task exceeding the
capabilities of the individual’s physical or mental abilities (NSC, 2001).
Developing HFACS 21
Substandard practices of operators are subdivided into crew resource management and
personal readiness. Crew resource management is the proper coordination of the crew during
operations also including communications within and outside the crew. Personal readiness
identifies individual’s expectations and performance levels such as physical and mental
preparedness for the task. One item of consideration stated in the NSC Resource is that
preconditions such as personal readiness may not be standard practices, however does not violate
or relate to regulations (NSC, 2001).
Unsafe supervision is the third process which contains four primary categories. The four
supervisory categories are inadequate supervision, planned inappropriate operations, failed to
correct a known problem, and supervisory violations. Inadequate supervision contains the basic
principles of the supervisor providing the crew the opportunity to succeed through guidance,
training, leadership, motivation, and the proper role model. Planned inappropriate operations
identifies crews being placed in unacceptable risk adversely affecting performance in such ways
as improper pairing of crew members with minimal experience. Failing to correct a known
problem arises when known deficiencies among individuals, equipment, or training, as well as
inappropriate behaviors, unsafe atmospheres, or other unsafe areas continue to exist without
Developing HFACS 22
being corrected. Supervisory violations happen when there is willful disregard for the rules or
procedures, such as allowing an individual to perform a function without proper or sufficient
qualifications (NSC, 2001).
Organizational Influence is the final level identifying fallible decisions of upper-level
management which filters down through the organization. The three categories of organizational
influences include resource management, organizational climate, and operational processes.
Resource management refers to the management, allocation, and maintenance of organizational
resources including human, monetary, equipment, and facilities. Organizational climate refers to
the treatment of individuals and the climate of the organization. Organizational climate is broken
down into three further categories including structure, policies, and culture. Organizational
process is the formal process by which things are done in the organization. The organizational
processes can be further divided into three categories of operations, procedures, and oversight
(NSC, 2001).
Developing HFACS 23
The Federal Aviation Administration (FAA) published a document Human Error and
General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS in 2005.
The HFACS’s original framework was developed for the U.S. Navy and Marine Corps as an
accident investigation and data analysis tool for aviation incidents. Since its creation other
agencies have utilized the program including the FAA as a complimentary program. HFACS has
been cited by the Aeronautical Decision Making Joint Safety Analysis Team as a useful tool in
identifying the human error component of aviation accidents.
In the FAA document a set of research questions were developed to analyze the benefits
of the HFACS systems. The research revealed that most incidents were associated with multiple
causal factors. The data indicated skill based errors were associated with the largest percentage
of the accidents and the most fatalities (79.2%) followed by decision errors (29.7%), violations
(13.7%), and perceptual errors (5.7%). Violations performed by the operator increased the
chances of a fatal incident by 4 times. With the high number of skill based errors the cause was
identified as being most susceptible to distractions during low processing task, lower levels of
experience, and training. Reason (1990) defined skill based errors as those which occur during
the execution of routine events. Reducing skill based errors is identified as utilizing increased
Developing HFACS 24
experience and training, detailed checklist, increased automation of critical task, workload
management, and training. The conclusion of the report identifies that existing prevention
programs are not effective as they focus on the specific types of accident rather than specific
types of human error. Focusing on types of accidents provides interventions which are narrow in
scope producing change in aircraft, existing policies, or regulations (FAA, 2005).
The United States Department of Defense (DOD) (2005) Human Factor Analysis and
Classification System provides a mishap investigation and data analysis tool. The history
reported in the document provides statements from the Secretary of Defense in a memorandum
published on May 19, 2003. The Secretary stated “World-class organizations do not tolerate
preventable accidents. Our accident rates have increased recently, and we need to turn this
situation around. I challenge all of you to reduce the number of mishaps and accident rates by at
least 50% in the next two years”. The statement and ensuing memorandum resulted in the DOD
Safety Oversight Committee to provide guidance in accomplishing the directive. The committee
was charged with reviewing accident trends, advise on improvements, develop and implement
safety initiatives, and coordinate with other agencies to facilitate research, standards,
performance, education, and equipment. The evaluation of the safety oversight committee led to
the use of HFACS in all mishaps (DOD, 2005).
In an article from Jennings (2008) Human Factors Analysis & Classification applying the
Department Of Defense System During Combat Operations in Iraq identifies how the HFACS
system was adapted for combat. The taxonomy of the original HFACS remained constant with
unsafe acts, unsafe supervision, and organizational influences; however, preconditions for unsafe
acts changed considerably. The division of preconditions to unsafe acts is broken down into
environmental factors, condition of individuals, and personnel factors. Environmental factors
Developing HFACS 25
include two sub categories of physical environment and technological environment. Condition of
individuals was broken down into cognitive factors, psycho-behavioral factors, adverse
physiological states, physical/mental limitations, and perceptual factors. Personnel factors were
separated by coordination/communication/planning factors and self imposed stress (Jennings,
2008).
The other areas of difference are found in the causal factors. An example is made
utilizing a rollover incident analysis of a motor vehicle crash, which was plaguing the combat
arena. The article which identifies each of the divisions, categories, subcategories, and causal
factors relating to the crash was identified as follows:
Developing HFACS 26
Division Category Causal Factors Unsafe Acts Skill Based Errors Overcontrol/Undercontrol Unsafe Acts Violations Lack of Discipline Preconditions Condition of Individual Fatigue-Physiological/Mental Unsafe Supervision Inadequate Supervision Oversight Inadequate
Unsafe Supervision Planned Inappropriate Operations Limited Total Experience
Unsafe Supervision Planned Inappropriate Operations Risk Assessment-Formal
Organizational Influences Organizational Climate Unit Organizational Values/Culture Organizational Influences Organizational Climate Unit Vehicle/Equipment Change Organizational Influences Organizational Process Organizational Training
Without full information of the incident, total comprehension is not gained; however, the
HFACS analysis does provide an example of the program and depth of causal factors and
behaviors beyond the operator. Jennings also states that the DOD-HFACS is an effective tool
that can be used to identify and mitigate hazards, management issues, and accidental loss to
improve the combat environment. The DOD-HFACS system is attributed to identifying and
providing mitigation programs which provided a 62% decrease in rollovers and a 75% decrease
in fatal rollovers during a three year period. The rollover prevention program provided a primary
focus on management due to the DOD-HFACS evaluation of the events (Jennings 2008).
The Australian Transport Safety Bureau (ATSB) (2007) published a document Human
Factor Analysis of Australian Aviation Accidents and Comparison with the United States. The
document identifies the benefit to aviation safety by increasing knowledge of human factors
includes the ability to identify safety problems, to design evidence-based interventions that
reduce error frequency, to learn from solutions of others, and to provide opportunities for others
to learn from initiatives. Validation of HFACS in the document identifies successful use in
aviation, road, rail transportation, medical, oil and mining industries. The HFACS program is
Developing HFACS 27
also utilized by military and civilian organizations in the United States, Canada, United Kingdom,
India, Israel, Greece, and the Netherlands. With the increasing variety of industry and
international use, HFACS is established as a reliable and valid accident classification tool. The
international evaluation by Australian Transport Safety Bureau reaffirmed there were differences
in contributory factors between the countries. Skill based errors still held the highest number of
causal factors followed by decision errors, violations, and perceptual errors (ATSB, 2007).
Human Error Investigation Software Tool (HEIST) developed by the Department of
Transportation (DOT) for the Federal Railroad Administration (FRA) in 2007 states that human
factors are a leading cause of train accidents and incidents in the United States. The document
identifies that human factors go beyond crewmembers on the track and include management
support and oversight, procedures, technology, facilities, and culture. In 2004 DOT initiated the
development of systematically structured software to provide accident analysis on human factors
(DOT, 2007).
With the development of the software, the following tasks were set to be examined; to
identify an appropriate human factors framework, to document the practice in accident
investigations, develop a set of user requirements, and to produce an initial concept of operations.
HEIST was based on Reason’s (1990) accident causation theory and structured around a
validated human factors classification system HFACS developed by Wiegmann & Shappell
(2003). The HEIST program as modified from the original HFACS program provides changes in
operator acts (unsafe acts), preconditions for operator acts, and organizational factors with no
change in supervisory factors, and an additional category of outside factors. Operator acts
(unsafe acts) are separated into errors and violations as in the original HFACS. Violations are
broken down into routine and exceptional with the addition of acts of sabotage. Errors are broken
Developing HFACS 28
down into skill based errors, decision errors, and perceptual errors. Unlike the original HFACS
skill based errors and decision errors are broken down further. Skill based errors subcategories
include attention failure, memory failure and technique error. Decision errors subcategories
include procedural error, poor choice and problem solving (DOT, 2007).
Preconditions for operator acts were changed mostly in the wording of condition of
operators, personnel factors, and the additional category of environmental factors. Environmental
factors are subdivided into physical environment and technological environment. Condition of
operators is subdivided into adverse mental states, adverse physiological states, and
physical/mental limitations. Personnel factors are subdivided into crew resource management
and personal readiness (DOT, 2007)
Developing HFACS 29
Supervisory factors remained relatively unchanged from the original HFACS taxonomy
being divided into inadequate supervision, planned inappropriate operations, failure to correct
problem, and supervisory contraventions (violations) (DOT, 2007).
Organizational factors were changed from the original HFACS taxonomy by the addition
of subcategories under resource management, organizational climate, and organizational process,
and the addition of change management. Resource management was subdivided into human
resources, equipment facility resources, and monetary budget resources. Organizational climate
was subdivided into organizational structure, organizational policies, and organizational culture.
Organizational process was subdivided into organizational operations, organizational practices
and procedures, and organizational (safety) oversight (DOT, 2007).
Developing HFACS 30
The new field which was added was outside factors which were subdivided into
regulatory oversight and economic/political/social/legal environment (DOT, 2007).
A unique approach to the use of the human factor analysis was identified in A System
Perspective on Road User Error in Australia: Swiss cheese and the road transport system by
Salmon, Reagan and Johnston (2008). Salmon, et al, cites research which identified driver error
contributing to 75% of roadway crashes. Despite the identification of error related crashes
causing the major problem, further research has been limited. The document identified research
toward a framework for an error tolerant road transportation system. The theory provided an
outlook of increasing tolerance of errors instead of eradicating errors. The theory was based on
Developing HFACS 31
the fact that drivers will always commit errors, which will never completely be avoided.
However, understanding and preparing for errors will decrease the severity (Salmon, et al, 2008).
A taxonomy was created to better identify errors and causal factors contributing to the
errors. The taxonomy was divided into five primary categories including; road infrastructure,
vehicle, road user, other road users, and environmental conditions. Road infrastructure is further
classified by road layout, road furniture, road maintenance, and road traffic, rules, policy and
legislation. Vehicle is broken down into human machine interface, mechanical, maintenance, and
inappropriate use of technology. Road user subcategories are physiological state, mental state,
training, experience, context related, non-compliance and knowledge, skills and abilities. Other
road users are other driver behavior, passenger effects, pedestrian behavior, bicyclist behavior,
law enforcement, and other road user behavior. Environment conditions consist of weather,
lighting, time of day, and road surface conditions (Salmon, et al, 2008).
With these areas identified the information is then further classified into whether the
errors are classified as a slip, lapse, mistake or violation to complete the evaluation. The error
taxonomy which was classified to evaluate roadway crashes was based on the principles of
identifying the engineering, enforcement, and education needs in preventing or tolerating errors
causing crashes (Salmon, et al, 2008).
The Field Guide to Understanding Human Error was originally developed in 2002 and
revised in 2006 by Sidney Dekker (2006) of Land University in Sweden primarily outlining
investigation theory. Dekker (2006) identifies two outlooks on identifying errors. The first
outlook is when an investigation stops after identifying the cause of the mishap or human error,
also referred to as “The Old View” by Dekker. The second identifies the human error as a
symptom of deeper trouble found in the tools, tasks, operations, organization, and environment
Developing HFACS 32
also referred to as “The New View” by Dekker. An entire chapter of the book is dedicated to
hindsight bias because all investigations are evaluating incidents with hindsight. A reaction to
failure creates bias in many instances while reviewing past events reverting to “The Old View”.
Dekker (2006) outlines the problem with reacting to failure as interfering with understanding the
total problem. He implies the more reaction to failure the less the cause is understood. In
evaluating an incident if the evaluator focuses on their knowledge of the incident or hindsight
bias instead of why the individuals made the decisions the extent of the cause will not be
determined. Hindsight causes an outlook that a sequence of events inevitably lead to an outcome,
a sequence of events is linear without interruptions and causality is oversimplified (Dekker,
2006).
Dekker (2006) outlines one of the primary keys in evaluating human error is
understanding human behavior by looking at the incident as the individuals involved participated
in the incident, “put yourself in their shoes” to understand why they made the decisions when
they made them. In evaluating the decisions the individuals made when they made them with the
factors present, it may be identified that the right decision was made at the time, unlike
evaluating with hindsight bias where the decisions are assumed incorrect due to the cause of
failure.
Dekker (2006) utilizes the analogy of the sharp and blunt end of the accident with the
sharp end being the failure caused by the operator and the blunt end being the organizational
factors leading up to the cause. The sharp end identifies active failures (the act), while the blunt
end identifies latent failures (preconditions, supervision, and organizational issues). To identify
issues with organizational problems or deficient safety culture, Dekker outlines resilient
organizational qualities or a strong safety culture.
Developing HFACS 33
Resilient organizations include management commitment having a high priority in safety,
and involvement understanding the operational safety and risk. Resilience also identifies
employee empowerment where the employees feel they can make a difference by influencing
policies and taking pride in safety; incentive structures connected to safety behaviors; and
reporting systems providing reporting, learning, and improvements in safety. A safety culture is
identified as a system that allows the boss to hear bad news, which provides an environment for
the employees to feel comfortable in delivering bad news knowing management will act upon it
with out repercussions. An example of delivering, evaluating, and disseminating information is
through the work of physicians in the morbidity and mortality conference where errors causing
damage or death are communicated to provide causal understanding and prevention (Dekker,
2006).
Managing The Unexpected by Weick and Sutcliffe (2007) is based on developing and
maintaining high reliability organizations (HRO). Organizations classified as high reliability
organizations are those which require high performance where the potential for error is
overwhelming such as air traffic control, aircraft carriers, hostage negotiators, nuclear power
plants, and firefighters. High reliability organizations provides a mindful infrastructure that
continually tracks small failures, resist oversimplification, remains sensitive to operations,
maintains capabilities for resilience, and takes advantage of shifting locations of expertise.
Failure within an HRO is classified as having a much greater potential for being catastrophic
than within non HRO organizations due to the nature and environment of the work (Weick &
Stancliffe, 2007).
Weick and Stancliffe (2007) define preoccupation with failure as an HRO’s ability to
treat any lapse as a symptom of the system or something which individually or combined with
Developing HFACS 34
another lapse can have sever consequences. An HRO will address all incidents which occur to
determine cause and effect in order to prevent future incidents. Reluctance to simplify could also
be identified as being non complacent. An HRO being in a complex, unstable, and unpredictable
environment while experiencing oversimplification or complacency could lead to failures.
Sensitivity to operations is being attentive to the front line where the work gets done. HRO’s are
less strategic and more situational. With well developed situational awareness, adjustments to
prevent errors are continuous. Commitment to resilience allows an organization to maintain
stability and continuous operations after a major mishap or under continuous stress. Resilience
keeps errors small and maintains workarounds demanding knowledge of technology, the system,
coworkers and oneself (Weick & Stancliffe, 2007).
An HRO places priority on training, personnel with varied experience and skills, and
making do with what they have to take worst case scenarios and drill out solutions. Deference to
expertise is developed through HRO’s who cultivate diversity in personnel who may have a wide
array of knowledge and experience. With deference to expertise the decision making is not
terminated by rank, instead it is pushed down to others on the front line with the most expertise
not necessarily rank. Information outlining HRO provides examples of failure prevention and
positive behaviors such as situational awareness, crew resource management, and many other
examples which are outlined in the human factor analysis classification system (Weick &
Stancliffe, 2007).
Gary Klein (1998) identified how people make decisions in Sources of Power where he
provides extensive studies on different groups of people and the methods for their decisions. One
of Klien’s primary study groups was firefighters where he outlines the recognition-primed
decision model (RPD). To understand recognition-primed decisions Klien first defines a decision
Developing HFACS 35
as actively comparing two or more options in a process of comparative evaluation. The
recognition-primed decision model developed when the findings resulted in decisions being
made without comparing options. In the studies of the firefighter’s decisions, it was found that
decisions were based off of experience instead of comparison. The decisions based on experience
proved to be reasonable, rapid decisions, except when the individual had not experienced the
environment (Klein, 1998).
The decisions made were classified as singular evaluation strategy which would
determine the course of events unless the choice did not work where other considerations would
be made working toward a comparative evaluation strategy. The recognition-primed decision can
be defined as recognizing the situation as familiar (relating to previous incidents) and
recognizing a course of action likely to succeed. Recognizing the situation may also be combined
with evaluating the course of action with the individual imagining how the incident will play out.
The one step that is left out from the comparative evaluation is diagnosing the situation which
may be done if the course of action is not successful or as a follow up to ensure continuing the
chosen course. The best explanation of recognition-primed decision was made using the analogy
of a slide show. Every individual’s experiences are stored in a slide show (previous incidents)
and when a new incident occurs the individual chooses a slide (previous experience) which most
closely matches the incident at hand and makes the decisions based on the chosen slide (Klien,
1998).
Klien (2003) further investigates recognition-primed decision making in The
Power of Intuition. Again evaluating firefighters and military personnel Klien carries the quick
decision making process a step further identifying intuitive decision making. Similar to
recognition-primed decision making, intuitive decision making is defined by Klien as the way we
Developing HFACS 36
translate our experience into action. As Klien identified intuition in Sources of Power he
exemplified it in The Power of Intuition with his initial work based primarily on firefighter’s
decision making process (Klien, 2003).
Klien (1998) identifies why good people make poor decisions, as poor decisions
are not necessarily made, as much as they are created by poor information, environments,
knowledge, and experience. Klien also found that stress does not create poor decisions; however
it distracts attention, prevents using working memory, and keeps the individual from gathering
further information. Poor decisions would be better classified as poor outcomes based on the fact
that the individual made the decision based on the information and expertise at the time of the
incident. Klien provides the best defense for poor outcomes is expertise which allows the
decision maker to act rapidly with certainty (Klien, 1998).
Uncertainty creates doubts also known as risks, probabilities, confidence, ambiguity,
inconsistency, instability, confusion, and complexity resulting in poor outcomes. Uncertainty
exists when information is missing, unreliable, conflicting or complex. One example of
uncertainty is when the individual explains away all of the indicators of a problem. Many times
indicators of problems exist which individually do not indicate concern; however, collectively
indicate a primary identifier. Uncertainty is also classified in levels directly related to the level of
knowledge, data, and understanding (Klien, 1998).
Procedures
The procedures for the research of this project began with an extensive literature review
consisting of periodicals, text books, manuals, and previous research. The identification of the
selected literature was derived from the National Fire Academy Learning Resource Center,
Developing HFACS 37
internet web searches, and from professionals in the HFACS field. The review provided an
extensive knowledge of the understanding and development of HFACS in multiple industries.
To begin to evaluate the development of the use of HFACS in the fire service the
National Fire Fighter Near-Miss Reporting System provided assistance with data obtained from
the near-miss reporting since its inception. The Near-Miss data provided some information
regarding causal factors as it collected data from selective causal factors in HFACS. Evaluation
of the data was performed to determine causal factors previously identified in the fire service.
The next step included combining all of the categories, subcategories, and causal factors
which were being utilized by the industries identified in the literature review. The merger of the
systems created overlaps of categories, subcategories, and an abundance amount of causal factors.
To provide the first step in the evaluation process, the current and previous Executive
Fire Officers in North Carolina was requested to assist with evaluating the merged systems. The
participants were requested to meet at the North Carolina Office of State Fire Marshal to achieve
two objectives including evaluate the combined systems to determine the relation to the fire
service and to utilize the system in firefighter fatality reports to ensure the categories,
subcategories, and causal factors effectively capture the needed data for the fire service. Prior to
the evaluation date all of the evaluators were sent the article Human Factor Analysis
Classification Applying the Department of Defense Program to Combat Operations in Iraq by
Jennings (2008) to provide as a primer. This process narrowed down the system utilizing
portions of all three industry systems.
The second step of the evaluation program was to evaluate the categories, subcategories
and causal factors which had been determined by the initial evaluation. The information was then
put into a spread sheet with descriptions of each factor, and evaluator input for each causal factor
Developing HFACS 38
in three areas including; need, probability and priority. The need was available for the evaluator
to determine whether the causal factor was needed by an indication of yes or no. Probability had
four options for the evaluator to select - frequent, often, rarely, and never. Priority had three
selections of high, medium and low. Upon completion the evaluators returned the spreadsheet
with their selections which allowed for compilation and evaluation of the responses. Based on
need, probability, and priority the causal factors were further narrowed to ensure the highest
priority and most probable factors were utilized with the least number of factors.
The final procedure was to develop a flow chart to illustrate the categories, subcategories,
and causal factors or codes. The flow chart was established based on Shapell & Wiegman’s
(2003) illustration of a taxonomic framework. The flow chart provides a greater understanding of
the system identifying the proceeding from category to category.
The primary limitation of the procedures was the number and variety of evaluators. The
current and previous EFO students in North Carolina number 18 from a wide variety of
organization types; however, the number participating in the primary and secondary evaluation
was limited. The second limitation was the amount of education and training on HFACS prior to
the work by the evaluators. Complete evaluation of the HFACS tool is also limited by the
number and types of incidents available. The final and most extensive limitation is the amount of
data on specific causes of incidents and injuries in the fire service.
Results
The path to develop HFACS has been extensive in identifying the necessary information
in order to code it for the fire service. With little cross reference for the fire service, the
development required utilizing other industry tools and evaluating the results for the fire service.
Developing HFACS 39
The one tool in the fire service, which is utilizing a hybrid HFACS is the National Fire Fighter
Near-Miss Reporting System developed by the International Association of Fire Chiefs. By
utilizing the Near-Miss database some of the categories and causal factors were identified. The
database consists of 1817 events starting since 2005. The top five incidents that were identified
in 1,429 reports in the data base included:
Type of Incident Percent
Fire Emergency (Structure, Wild land, Vehicle) 43.02%
Vehicle Event (Responding to or from) 26.40%
Training Activity 10.12%
Non Fire Emergency (Rescue, Extrication, EMS, Service) 6.63%
On Duty Activity (Apparatus Check, etc.) 5.20%
Other 18.75%
Utilizing the HFACS model in 447 reports of the Near Miss program the following identification
of the divisions was found:
HFACS Division Percent
Unsafe Acts 47.87%
Preconditions to Unsafe Acts 31.32%
Unsafe Supervision 11.41%
Organizational Influences 8.28%
Developing HFACS 40
In the Near Miss program the reporting individual has the ability to report multiple contributing
factors. The following information is developed from an average of two factors in 1,242
incidents. In the reporting system, definitions of the contributing factors are not listed on the web
site so when report submitters select the contributing factors, it is unknown what their knowledge
or perceptions of the definitions are.
Contributing Factor Percent
Decision 17.92%
Human Error 16.7%
Situational Awareness 13.25%
Other 11.97%
Individual Action 8.15%
Equipment 8.1%
Communication 7.15%
Command 5.55%
Accountability 3.75%
Training Issue 2.95%
Procedure 2.85%
Weather 1.65%
Other choices for contributing factors that are not listed include; protocol, staffing, task
allocation, teamwork, unknown, SOP/SOG, horseplay, and fatigue. All of these factors had a
value of less than 1% in the database (National Firefighter Near Miss Database, 2008).
Developing HFACS 41
A focus group was established at the NCOSFM to evaluate HFACS for the fire service,
after merging the system utilized by the Naval Safety Center, Department of Defense, and
Department of Transportation where each area was evaluated on the need, probability and
priority for the fire service. The following structure was identified as the most needed with the
highest probability or priority for the fire service having divisions, categories, and subcategories
as follows:
Division Unsafe Acts Category Errors Violations
Sub Category Skill Based Routine
Decision Exceptional Perceptual
Division Preconditions to Unsafe Acts
Category Condition of Operator Personnel Factors Environmental
Factors Sub
Category Cognitive Crew Resource
Mgmt Physical
Environment Psycho-Behavioral
Factors Personnel ReadinessTechnological Environment
Adverse Physiological State Self Imposed Stress
Perceptual Factors
Coordination Communication
Planning
Division Unsafe Supervision
Category Inadequate Supervision
Planned Inappropriate Operations
Failed to Correct Known Problem
Supervisory Violation
Developing HFACS 42
Division Organizational Issues
Category Resource ManagementOrganizational
Climate Organizational
Process Human Resources Structure Operations
Monetary Resources Policies Procedures Equip/Facility
Resources Culture Oversight Acquisition Mgmt
Establishing the structure was the first step in the process, to identify behaviors. It was necessary
to establish causal factors of each subcategory. When developing the causal factors or codes it
was determined that examples would be necessary so the user could clearly make a decision. The
following information contains the causal factors and examples developed by the focus group for
each category:
Unsafe Acts Causal Factors Examples
Decisions Skill Based Errors
Breakdown in visual scan Did not see the floor was gone Poor technique Took a 1 3/4 line instead of 2 1/2 Failed to prioritize attention Did not ventilate with fire in the rafters
Developing HFACS 43
Task overload Not enough support with multiple incidents
Negative habit Driving with engine break on in adverse conditions
Failure to see and avoid Drove into a ditch
Distraction Focusing on communications instead of driving
Checklist error Did not check apparatus off Procedural error Started PPV before ventilating structure
Overcontrol / under control of situation Lost control of apparatus
Decision Errors Inappropriate maneuver/procedure Did not park apparatus to protect scene Inadequate knowledge of systems, procedures Did not know how to get foam on line Exceeded ability Attempted attack with one crew needing more Wrong response to condition Water flowed from outside on inside crew
Risk assessment-during operations Objective not changed with changing conditions
Task miss-prioritization Started attack before rescue Necessary action - rushed Responded to rapidly Necessary action - delayed Did not start water supply when needed Necessary action - ignored Needed water supply Attention failure Did not recognize collapse signs
Poor choice Chose to go in without a partner
Perceptual Errors Visual illusion Road lanes obscured by wet pavement Spatial disorientation Fog, smoke, no visibility Misjudged distance, speed, clearance Too fast for curve
Misperception Underestimated incident factors
Violations Routine
Inadequate briefing Did not pass on info about hazards Violation of orders, regulations, SOP's Did not establish a RIT Failed to inspect apparatus Did not find loose equipment Based on risk assessment Did not perform walk around Lack of self discipline Failed to use safety equipment
Exceeded weather condition Drove too fast for conditions
Exceptional Exceeded limits of apparatus Not enough stopping distance Accepted unnecessary hazard Did what they were told knowing it was unsafe Not current/qualified Did not have 1403 classes entering live burn Failed to obey general statutes Did not wear seat belt Willful disregard Did not stop for a red light
Developing HFACS 44
Preconditions to Unsafe Acts Causal Factors Examples
Condition of Individual Cognitive Factors
Inattention Did not pay attention to conditions Mental task over saturation Too many objectives for one person Confusion Did not understand orders Distraction Thinking about personal problems Geographic miss orientation (lost) Lost in the structure Loss of Situational Awareness Caught in a flashover Stress Outside events causing stress Alertness Line officer Mental fatigue Continuous information processing overload Tunnel Vision Going to the smoke instead of size up Memory lapse/failure Did not call for mayday when lost
Technical/procedural knowledge Shutting off chlorine tank without knowledge
Psycho-Behavioral Factors Emotional state Not recovered from CIS Overconfidence Inherent personal attribute Complacency Not wearing helmet strap Inadequate motivation Don’t want to be there Misplaced motivation Wanting to look good Overaggressive Taking unnecessary chances Excessive motivation to succeed Competitive nature Get-home-it is/get-there it is Just wanted to get there or go home Motivational exhaustion No longer motivated to complete objectives Information overload Too much unnecessary info
Inadequate experience Did not have enough experience
Adverse Physiological States Medical illness Come to work with flue Hypoxia Not wearing SCBA in O2 deficient Physical fatigue Worked for over 48hrs Intoxication Drinking or illegal drugs Effects of over the counter medication Taking ephedrine for weight loss Prescribed drugs Taking painkillers Operational injury/illness Sprained ankle and continued working Pre-existing physical illness, injury, or deficit Overweight Dehydration Overheated without fluids Physical Task Over saturation Overworked Visual limitations Could not see due to SCBA mask Inadequate reaction times Did not react quickly to high heat
Incompatible physical capabilities Was not physically fit
Perceptual Factors Misperception of operational condition Did not realize fire in the attack Misinterpreted/misread condition Did not read smoke
Developing HFACS 45
Auditory cues Did not hear cylinder venting
Personnel Factors Crew Resource Management
Failed to conduct adequate brief Did not inform crew of objectives Lack of teamwork Worked as individuals Lack of assertiveness Officer did not command direction Poor communication Crew did not communicate up and down Poor coordination Ventilation and attack worked against Misinterpretation of communications Did not confirm communication Lack of trust Crew did not trust decisions
Failure of leadership Leader did not lead
Personal Readiness Adequate crew rest No rehab between operations Inadequate training Crew not trained for operations Self-medicating Taking meds causing inattention Overexertion prior to duty No rest between off and on duty activity Poor dietary practices Weight loss diet causing fatigue
Pattern of poor risk judgment Continuously driving fast
Self-Imposed Stress Physical fitness Not physically fit Alcohol Drinking alcohol Drugs/supplements/self medication Meds causing inattentiveness Nutrition Not enough or too much Inadequate rest Worked too many hours Unreported disqualifying medical condition Not notifying of seizure condition
Coordination/Communication/Planning Factors Task delegation Objectives not delegated to others Communicating critical information Did not inform of roof sagging Standard/proper terminology Using ten codes or slang with multi agency Challenge and reply Did not challenge leader of safety issue Mission planning Did not plan for the mission Mission briefing Did not brief crew of mission
Task/mission reevaluation Did not reevaluate objectives
Environmental Factors Physical Environment
Weather Adverse weather Terrain Driving down a grade Lighting Not enough lighting Toxins CO levels not monitored Vision restricted by icing/windows fogged etc Apparatus mirrors fogged while backing Vision restricted by meteorological conditions Apparatus strobes on during snow Vision restricted in workspace by dust/smoke etc Unable to see due to smoke conditions Wind Working in wind over 60mph
Developing HFACS 46
Thermal stress-cold Fighting fire at -10 F Thermal stress-heat Fighting fire at 95 F and 90% RH Lighting of other vehicle Driving toward high beams
Noise interference Unable to hear radio due to engine noise
Technological Environment Equipment/controls design Gauges not able to be seen while driving Seating and restraints Restraints don't fit over PPE Instrument and sensory feedback systems Ignored door open light Visibility restrictions Unable to see mirrors on apparatus Work environment incompatibility with human Apparatus does not accommodate tall driver Personal equipment interference Gloves do not work with coat Communication - equipment failure Portable radios do not work inside building
Unsafe Supervision Causal Factors Examples
INADEQUATE SUPERVISION Failed to provide proper training No firefighter survival training Failed to provide current adequate procedures Did not give proper up to date guidance Failed to recognize fatigue Did not notice fatigue Failed to track qualifications Unqualified individual performed ops Failed to track performance Did not ensure individual performance Failed to provide operational guidelines or policies Did not ensure SOG's followed Over-tasked supervisor Lost span of control Loss of supervisory situational awareness Got too deep for conditions Leadership/supervision/oversight inadequate Officer fighting fire instead of leading Supervision personality conflict Did not like crew Supervision lack of feedback Did not give critique Failed to hold crew responsible for actions Did not correct poor actions Lack of personnel accountability (where people are) Did not perform PAR
PLANNED INAPPROPRIATE OPERATIONS Poor crew pairing New officer new driver new back man Failed to provide adequate briefing Did not inform of conditions Risk outweighs benefit Fully involved house attempt rescue Failed to provide adequate opportunity for crew rest No rehab Excessive tasking/workload Exceeded span of control Ordered/led on mission beyond capability Fighting wild land in structural PPE Limited recent experience Officer driving after not driving 5 yrs Limited total experience One interior fire per year Proficiency No interior fires no interior fire training Risk assessment during size-up Did not do a walk around
Developing HFACS 47
Authorized unnecessary hazard Allowed unqualified individual to operate
FAILED TO CORRECT A KNOWN PROBLEM Failed to correct inappropriate behavior Did not provide discipline Failed to identify and correct risky behavior Allowed individual to take risk Failed to correct safety hazard Did not stop unsafe act Failed to initiate corrective action Failed to report unsafe tendencies Did not report continuous speeding Personnel management Did not ensure crew accountability
Operations management Did not have proper ICS
SUPERVISORY VIOLATIONS Authorized unqualified crew Allowed non 1403 FF in live burn Failed to enforce rules and regulations Did not discipline Violated procedures Sent crew in swift water w/o PFD Authorized unnecessary hazard Allowed crew to remove SCBA in IDLH Willful disregard for authority by supervisors Did not have crew exit when instructed Documentation incorrect or incomplete Falsified certification
Organizational Influences Causal Factors Examples
RESOURCE MANAGEMENT Human Resources
Selection Firefighters selected based on no physical requirements
Staffing/manning Not meeting NFPA 1710 or 1720
Training Not requiring 1403 before live burn
Monetary/Budget Resources Excessive cost cutting Reduction of personnel due to finance
Lack of funding Can not purchase new PPE
Equipment/Facility Resources Poor design Truck designed overweight Purchasing of unsuitable equipment Purchasing low bid
Failure to correct known design flaws Equipment in cab not secured
Resource/Acquisition Management Operator support Individual without proper PPE Acquisition process Purchases delayed due to bureaucracy Attrition Excessive leaving of organization Accession/selection Officers selected subjectively Personnel resources Not enough people to do the job
Informational resources/support Communication open up and down the organization
Developing HFACS 48
ORGANIZATIONAL CLIMATE Structure
Chain of Command Administration or operators did not use chain Communication Information does not go up and down Accessibility/visibility of supervisor Supervisor does not work with the crew Delegation of authority Supervisor micromanages crew
Formal accountability for actions Supervisor does not conduct performance evaluation
Policies Promotion Organization does not have job descriptions Hiring, firing, retention Organization does not have a dismissal policy Drugs and alcohol Organization does not have an alcohol policy
Accident investigations Organization does not have an investigation program
Culture
Norms and rules Rule states always have 2 in 2 out but norm is to go in
Organizational customs To alienate rookies until they prove themselves
Values, beliefs, attitudes Organization has little regard for safety at fires
ORGANIZATIONAL PROCESS Operations
Operational tempo The IC rushes the operation
Social pressures The public is saying that there is someone in a fire
Organization The Incident Mgmt system not organized Time pressure The organization expects arrival in 5 min
Management No ICS on the scene
Procedures Performance standards Organization does not evaluate performance Clearly defined objectives Objectives are not identified or stated
Procedures/instructions about procedures No instructions of technical procedure
Oversight Established safety/risk mgmt programs No risk management or safety program Organizational training issues/programs No up to date training on light weight trusses Organizations ability to change Organization resistance to change Modern practices Organization deploys booster line on car fire Managements monitoring of resources, climate Organization does not analyze injuries and processes to ensure a safe work environment
To provide a more fluid understanding of the HFACS system illustrating the divisions, categories,
subcategories, and causal factors a flow chart was developed and is located in the appendix
(appendix B).
Developing HFACS 49
Once the focus group evaluated and refined the system, it was utilized in evaluating
firefighter fatality reports from NCOSFM files to determine its effectiveness. In most reports that
were assessed, the primary area which could be evaluated was unsafe acts. Due to the lack of
information contained in the reports, it was difficult or impossible to definitively determine the
preconditions to unsafe acts, supervisory issues, and organizational issues. The focus group then
attempted to answer the preconditions to unsafe acts, supervisory issues, and organizational
issues by interjecting hypothetical information in the fatality reports to evaluate the tool. The
hypothetical information provided a better understanding of the analysis to complete an HFACS
evaluation; however it was only hypothetical data. To further ensure the effectiveness of the tool
each participant had the opportunity to provide a major incident from their organization and
utilize HFACS to evaluate the incident.
The evaluation of actual incidents with HFACS and the causal factors which had been
identified provided several conclusions:
1. Every incident produced multiple causal factors. There was no one factor that could
be traced back to be the definitive cause. There were multiple factors that would have
prevented the incident.
2. Every evaluation identified behaviors which could be modified or changed to prevent
future incidents from occurring.
3. Every incident evaluated provided organizational factors that played a role in the
incident occurring or if changed would have prevented the incident from occurring.
4. Identifying causal factors in all four divisions; unsafe acts, preconditions to unsafe
acts, supervisory issues, and organizational issues provided a complete analysis of the
incident and all factors involved instead of only focusing on the individual.
Developing HFACS 50
Discussion
It is evident through the evaluation that firefighter fatalities and injuries have only
declined by the decline of structure fires. USFA (2008) Structural collapse fatalities have even
seen an increase in the last eight years evaluated. NIST (2003) Understanding why firefighters
are being injured and killed is identified in broad factors that do not provide specific measurable
behaviors that can be changed. To identify injury prevention measures based on information
available focusing on the high probability identified would include; firefighters between the age
of 20 to 39, overexerting or straining, during fire development, extinguishing the fire or
neutralizing the incident (USFA, 2008). With the above highest percentage of factors identified,
the preventative behaviors may be as follows:
1. Target Audience – Firefighters ages 20 to 39
2. Objective- Teach firefighters not to overexert or strain themselves while extinguishing
the fire during the growth stage of the fire.
The above target audience and objective has some value; however, the broadness of the
statement might as well be a simplified statement – “don’t put the fire out”. Another example of
the broadness of what kills firefighters in structural collapse is identified by nature of death and
cause. Nature of death in structural collapse includes: asphyxiation, burns, internal trauma, and
other causes. The cause of firefighter deaths in structural collapse include caught or trapped, or
struck or had contact with an object (NIST, 2004).
Moore-Merrell, et al (2008) provided a deeper insight into contributing factors. Though
the data was clustered, it provided several contributing factors as the leading causes. These
causes grouped together included; decision making, lack of communication, standard operating
guideline or procedure breech, protocol breech, human error, lack of situational awareness, crew
Developing HFACS 51
size, lack of wellness or fitness, fatigue and weather or act of nature. One discrepancy found of
the cluster is that all of the factors in the cluster with the exception of weather or act of nature are
human error factors. The research did identify lack of situational awareness as the dominating
contributing factor.
James Reason (1990), Douglas Wiegmann and Scott Shappell (2003), and the Naval
Safety Center (2006) provided a framework that specified methods of identifying causal factors.
The need for specific measurable modifiable behaviors can be identified in causal factors.
Change will only be made to the operator if the operator is the only place an analysis is focused.
The Human Factor Analysis Classification System provided a focus beyond the operator into
preconditions, supervision and the organization. The Risk Assessment Code matrix also provided
a valuable example of a tool to identify the probability and severity of an incident defining the
level of risk it caused.
Jennings (2008), the Department of Transportation (2007), the Department of Defense,
the Australian Transportation Safety Bureau (2007) and Salmon (2008) identified uses of
HFACS in multiple fields. With HFACS being originally created for aviation the uses in other
fields provided a greater path in developing HFACS for the fire service. The most relative
industry to the fire service in the area of job skills was identified by Jennings (2008) in the
utilization of HFACS in the combat arena of Iraq.
The fire service utilizes a common term in public education called the three E’s. The
three E’s include education, engineering and enforcement. Salmon (2008) utilizing HFACS to
identify public issues with road ways highlighted the three E’s. The fire service should learn
from itself. To prevent injuries and fatalities we must identify the education, engineering, and
enforcement needs. The education needs to be done by identifying the specific and measurable
Developing HFACS 52
risk behaviors that can be changed. The fire service needs to ensure that engineering in human
factors is a top priority. The leaders both formal and informal of the fire service need to enforce
safe behaviors at all times.
Dekker (2006) provided good theory in accident investigation. The most prominent area
Dekker outlined was the reference to “The Old View” and “The New View”. The old view can
be classified as the operator did something wrong that caused the incident to occur. The new
view simply states that the evaluator should not look at the results and should put himself in the
shoes of the operator while attempting to understand the environment, situation, and information
the operator encountered which lead to the decisions made. The operator predominately did not
intentionally want to cause an adverse event to occur and if the evaluator can identify the
decisions of the operator without hindsight bias they may determine the operator did the best
they could do with what the organization provided.
To understand factors effecting the organization the book by Weick and Stucliffe (2007)
Managing the Unexpected was utilized. The theory of High Reliability Organizations is based on
organizations that either make few errors or recover rapidly from errors. The four areas of an
HRO includes: preoccupation with failure or always identifying symptoms, reluctance to
simplify or not being complacent, sensitivity to operations or management being attentive to the
job, and commitment to resilience or keeping errors small. An organization utilizing HFACS
would be a prime example of a High Reliability Organization.
To understand decision making, Klein (1998 & 2003) provided studies performed in the
fire service and military. The primary focus on firefighter decision making was a theory of
recognition-primed decision making. The brief synopsis of recognition-primed decision making
can be defined as decisions which are not made as the individual reacts to the environment.
Developing HFACS 53
Further explanation of recognition-primed decision making is - the mind is a slide show of
previous experiences. When the firefighter encounters an environment, the mind pulls the slide
closest to the environment and utilizes that slide or previous experience to deal with the current
situation. Klein also recognizes that poor decisions are actually only poor outcomes, due to the
fact that the individual made the decision based on the information and expertise at the time of
the incident.
Recommendations
The development of the Human Factor Analysis Classification System for the fire service
has identified itself as a valuable tool producing information that can be formulated into specific
measurable objectives. The development of the system divisions, categories, subcategories and
causal factors indicate the functions and performance of the fire service.
In the future the development of HFACS for the fire service will always be evolving as
the fire service evolves. The program must be initiated to determine if further refinement is
needed through evaluating multiple incidents deriving from different incident types. The HFACS
should be delivered in a beta form with further evaluation of incidents to ensure if the program
captures too much or too little data. The evaluation of the data collected will further evaluate the
necessary causal codes. The system once evaluated in beta form and utilized should be evaluated
annually to ensure data needs are being maintained.
To best utilize the HFACS to its fullest extent identifying the shortcomings of the
organization an evaluator without ties to the organization would be least bias. With the difficulty
in identifying your own shortcomings and providing those to management, utilizing an outside
evaluator would be most effective. For the best results, an evaluation of an adverse incident
should consist of a formal investigation completed by the organization affected with an HFACS
Developing HFACS 54
evaluation. The evaluation should be conducted by outside evaluators with the assistance of a
formal investigation team. If the effected organization can classify itself as a High Reliability
Organization, (one that can accept failure as a tool to improve operations) the organization may
be able to complete the formal and HFACS evaluation with internal personnel.
In addition to the HFACS, the Risk Assessment Codes (RAC) would provide great
insight into the severity and probability that specific types of incidents pose. The identification of
the RAC could be utilized to determine the extent or need of evaluation using HFACS. Every
incident should provide the information defined by the RAC: critical risk, serious risk, moderate
risk, minor risk, and negligible risk.
The value of utilizing the HFACS developed for the fire service identified itself while
evaluating previous incidents. Skyland Fire Rescue will need to implement the use of the
HFACS on all future incidents. Skyland’s utilization of the tool will provide insight into human
error on the levels of the operator, supervisor, and the organization. The HFACS does not need
to replace the formal investigation which details all of the specific information of the incident;
however, it should supplement the investigation by providing insight into human error and
preventable measures.
To provide a path in North Carolina to prevent firefighter injuries and fatalities, utilizing
HFACS with a specific incident would be the most effective method of collecting data. The best
practice would be to utilize the HFACS for all incidents; however, without some parameters this
may be an extreme task for the fire service. The Naval Safety Center’s (2006) severity
classification provides a starting parameter of Class B incidents creating $200,000 of damage or
more and injuries resulting in permanent or partial disability. Utilizing the “Three E’s of
Education” might provide a pathway for implementations. Education on evaluating incidents
Developing HFACS 55
utilizing HFACS should be provided to a group of evaluators in each region of North Carolina;
West, Piedmont, and East. Every fire department should be provided with basic information and
benefits of the program. Engineering of HFACS should be provided through continual evaluation
of the system. Enforcement and support would be maintained by the Insurance Industry requiring
the data of Class B incident to be compiled to reduce injuries and damages thus reducing claims
and liability.
If HFACS was utilized by the National Institute of Safety and Health’s (NIOSH)
Firefighter Fatality Investigation and Prevention Program (FFFIPP), human errors would be
identified from the operator to the organization. The HFACS evaluation would provide specific
and measurable behaviors which could be identified and disseminated throughout the fire service
to change behaviors. To prevent placing blame on the organization, the data obtained by NIOSH
FFFIPP could be captured, compiled, and presented as an annual document.
The long term goal of utilizing the HFACS program would be accomplished through a
software program which would allow the evaluator to manage the documentation. Software
development should be accomplished and provided through the United States Fire
Administration with instructions on usage. The software system should have an option of an
automatic upload of the data to a national database without using department or personnel
information. The national database would provide the specific behaviors needing to be changed
in the fire service.
In summary the following short and long term recommendations would lead to
identification of preventable specific and measurable behaviors causing injuries and fatalities in
the fire service.
Developing HFACS 56
1. Utilize the identified HFACS system for the fire service as a beta tool for
further evaluation with annual assessments after full release.
2. Utilize outside evaluators to assist in identifying organizational shortcomings.
3. Identify all incidents utilizing the Risk Assessment Codes to provide severity
and probability.
4. Implement the HFACS program at Skyland Fire Rescue as a supplement to
formal investigations to provide a complete incident analysis.
5. Implement the HFACS program in North Carolina on incidents with damage of
$200,000 or more and injuries with permanent or partial disability, using
trained evaluators in each region, supported by the insurance industry.
6. Provide the NIOSH FFFIPP with the HFACS evaluation tool to collect
summative data for annual reports.
7. Establish long term goals for the development of a HFACS software collection
tool and national database to be provided and managed by the USFA
coordinating with the IAFC National Firefighter Near-Miss Reporting System.
Developing HFACS 57
Reference List Australian Transport Safety Bureau. (2007). Human Factor Analysis of Australian Aviation Accidents and Comparison with the United States. Australian Government.Retrieved July 2, 2008, from http://www.atsb.gov.au/publications/2007/pdf/b20040321.pdf Brunacini, A. V. (2008). Fast/Close/Wet. Paper presented in symposium on Reducing Firefighter Deaths and Injuries: Changes in Concept, Policy, and Practice. Public Entity Risk Institute. Retrieved September 23, 2008, from http://www.riskinstitute.org/peri/images/file/S908-D2-Brunacini.pdf Cole, R. M. (2007). Identifying a Risk Evaluation Tool to Prevent Injuries and Fatalities. Emmitsburg, MD: National Fire Academy. Dekker, S. (2006). The Field Guide to Understanding Human Error (2nd ed.). Burlington, VT: Ashgate Publishing Company. Jennings, J. (2008). Human Factors Analysis & Classification Applying the Department of Defense System During Combat Operations in Iraq. Professional Safety, 44-51. Retrieved July 2, 2008, from http://www.asse.org/professionalsafety/docs/JenningsFeature_0608.pdf Klein, G. (1998). Sources of Power: How people make decisions. Cambridge, MA: Massachusetts Institute of Technology. Klein, G. (2003). The Power of Intuition. New York, NY: Doubleday.
Developing HFACS 58
Reference List Moore-Merrell, L., Zhou, A., McDonald-Valentine, S., Goldstein, R., & Slocum C. (2008). Contributing Factors to Firefighter Line-Of-Duty Injury in Metropolitan Fire Departments in the United States. International Association of Fire Fighters. Retrieved October 13, 2008, from http://www.iaff.org/08News/PDF/InjuryReport.pdf National Fallen Firefighters Foundation. (2005). Report of the National Fire Service Research Agenda Symposium. NFFF. Retrieved June 16, 2008, from http://www.fsi.uiuc.edu/documents/research/National%20Fire%20Service%20Re search%20Agenda%20Symposium.pdf National Institute of Standards and Technology. (2008). Trends in Firefighter Fatalities Due to Structural Collapse, 1979-2002. NIST. Retrieved June 15, 2008, from http://www.fire.nist.gov/bfrlpubs/fire03/PDF/f03024.pdf North Carolina Fatality Reports - 2008 - North Carolina Office of State Fire Marshal Fatality Database [Data file] Raleigh, NC: NCOSFM Reason, J. (1990). Human Error. New York: Cambridge University Press. Salmon, P., Regan, M., & Johnston, I. (2006). In A Systems perspective on Road User Error in Australia: Swiss cheese and the road transport system. Monash University Accident Research Center. Retrieved July 9, 2008, from http://www.monash.edu.au/muarc/reports/muarc257.pdf
Developing HFACS 59
Reference List Shappell, S., & Wiegmann, D. (2006). Developing a Methodology for Assessing Safety Programs Targeting Human Error in Aviation. Federal Aviation Administration. Retrieved June 19, 2008, from http://stinet.dtic.mil/cgi- bin/GetTRDoc?AD=ADA461400&Location=U2&doc=GetTRDoc.pdf United States Department of Defense. (2003). Department of Defense Human Factors Analysis and Classification System. Retrieved June 17, 2008, from http://safetycenter.navy.mil/hfacs/downloads/hfacs.pdf United States Department of Transportation. (2007). Human Error Investigation Software Tool. Retrieved June 9, 2008, from http://www.fra.dot.gov/downloads/Research/ord0715.pdf United States Fire Administration / National Fallen Firefighters Foundation (2004, April 14). Firefighter Life Safety Summit Initial Report. Retrieved August 3, 2007, from http://www.firehero.org/s567/images/Initial_Summit_Report.pdf United States Fire Administration. (2008). Fire-Related Firefighter Injuries in 2004. USFA. Retrieved June 14, 2008, from http://www.usfa.dhs.gov/downloads/pdf/publications/2004_ff_injuries.pdf United States Naval Safety Center. (2006). The Naval Flight Surgeon's Pocket Reference to Aircraft Mishap Investigation (6th ed.). Retrieved November 9, 2008, from http://www.safetycenter.navy.mil/AVIATION/aeromedical/downloads/PocketRef erencepdf Weick, K. E., & Sutcliffe, K. M. (2007). Managing The Unexpected (2nd ed.). San Francisco, CA: John Wiley & Sons, Inc.
Developing HFACS 60
Reference List Wiegmann, D. A., & Shappell, S. A. (2003). A Human Error Approach to Aviation Accident Analysis: The human factors analysis and classification system. Burlington, VT: Ashgate Publishing Company. Wiegmann, D., & Bouquet, A. (2005). Human Error and General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS. Washington: Federal Aviation Administration. Retrieved June 17, 2008, from http://stinet.dtic.mil/cgi- bin/GetTRDoc?AD=ADA460866&Location=U2&doc=GetTRDoc.pdf
Developing HFACS 61
Appendix A
Developing HFACS 62
Appendix B
Developing HFACS 63
Appendix B (Continued)
Developing HFACS 64
Appendix B (Continued)
Developing HFACS 65
Appendix B (Continued)
Developing HFACS 66
Appendix B (Continued)
Developing HFACS 67
Appendix B (Continued)
Developing HFACS 68
Appendix B (Continued)
Developing HFACS 69
Appendix B (Continued)
Developing HFACS 70
Appendix B (Continued)
Developing HFACS 71
Appendix B (Continued)
Developing HFACS 72
Appendix B (Continued)
Developing HFACS 73
Appendix B (Continued)
Developing HFACS 74
Appendix B (Continued)
Developing HFACS 75
Appendix B (Continued)
Developing HFACS 76
Appendix B (Continued)