Event Review Using HFACS(Template)

Instructor(s) Name(s)

Date

Human Error

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Performance Objectives

• List and describe 4 levels of failure using the Human Factor Analysis and Classification System (HFACS),

• Given a description of an event from INSERT DATE OF EVENT, use HFACS to identify error types presented during that event,

• ADD ADDITIONAL PERFORMANCE OBJECTIVES FOR THE COURSE AS NEEDED,

• INSERT EVENT SPECIFIC PERFORMANCE OBJECTIVES FOR THE COURSE, and

• Given a description of an event from INSERT DATE OF EVENT, identify the relevant INSERT RELEVANT STANDARDS OR PROCEDURES.

Reminder

• Event reviews and human factor analysis exercises are designed to further our understanding of event causes and prevent similar incidents from happening in the future.

• Event reviews and human factor analysis exercises are NOT about assigning blame.

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Human Factors Analysis and Classification System (HFACS) Overview

Unsafe Acts

Preconditions of Unsafe Acts

Unsafe Supervision

Organizational Influences

Source: Douglas Wiegmann and Scott Shappell (2003), adapted from James Reason (1990)

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Unsafe Acts

Unsafe Acts

Errors Violations

Decision Errors

Skill-based Errors

Perceptual Errors

Routine Exceptional

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Preconditions of Unsafe Acts

Preconditions of Unsafe Acts

Conditions of Operators

Personnel Factors

Adverse Physiological

States

Adverse Mental States

Physical / Mental

Limitations

Crew Resource

Management

Personal Readiness

Environmental Factors

Physical Environment

Technological Environment

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Unsafe Supervision

Unsafe Supervision

Inadequate Supervision

Supervisory Violations

Failure to Correct Problem

Planned Inappropriate Operations

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Organizational Influences

Organizational Influences

Resource Management

Organizational Process

Organizational Climate

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Event Details

DESCRIBE THE EVENT IN DETAIL (JUST THE FACTS, NO OPINIONS OR CONCLUSIONS)

Additional Information

PROVIDE ANY ADDITIONAL INFORMATION THAT MIGHT APPLY TO THE EVENT, RELATED TOOLS, ASSOCIATED PROCEDURES, ETC., THAT MAY PROVIDE CONTEXT FOR THE EVENT (JUST THE FACTS, NO OPINIONS)

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Review Exercise Instructions

• Use the INSERT EXERCISE DOCUMENT NAME

• Use the event description and the worksheet to identify all of the error types that were present in this event.

• The worksheet is divided into 4 sections (one for each of the levels in the HFACS model).

• Place a check mark in the column on the right for each of the categories, and subcategories, that you believe were factors in this event.

• For each section, write down the reason(s) you chose a category or subcategory in that section.

• Be prepared to share your thoughts with the class.

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Group Exercise – Answered(?)

USE THIS PAGE TO DESCRIBE THE TRAINING TEAM MEMBERS THAT ORIGINALLY REVIEWED THE EVENT AND LIST THE HFACS CATEGORIES THAT THEY AGREED WERE CONTRIBUTIING FACTORS FOR THE EVENT.

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Standards and Procedures

Which standards apply to this event?

Was there a violation?

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Questions?

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Course Quiz

You must achieve a grade of 80% on this quiz to Master this course material.

Quiz Question 1

Name the 4 levels of failure included in HFACS.

Unsafe Acts

Preconditions of Unsafe Acts

Unsafe Supervision

Organizational Influences

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Quiz Question 2

ADD A QUESTION ABOUT APPLICABLE STANDARDS OR PROCEDURES

ADD THE ANSWER TO THIS QUESTION HERE AND INCLUDE ANY ADDITIONAL INFORMATION TO EXPLAIN THE ANSWER

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Quiz Question 3

Which of the following is NOT a type of decision error?

a) Exceeded ability

b) Failure to correct known problem

c) Inappropriate procedure

d) Knowledge of the procedure was LTA

This (b) is a type of Organizational Influence found in the list of Equipment/Facility Resource errors.

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Quiz Question 4

ADD MORE QUESTIONS (ONE PER SLIDE) REGARDING THE EVENT THAT WAS REVIEWED, HFACS, OR RELATED TOPICS AND PLACE THE CORRECT ANSWER ON EACH SLIDE BELOW THE QUESTION (INCLUDE EXPLANATIONS FOR EACH ANSWER IF NEEDED).

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Thank you