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HUMAN FACTORS
Inputs
Accident & Injury
OrganizationalInfluences
SupervisoryFactors
Preconditionsfor
Unsafe Acts
Unsafe
Acts
Failed orAbsent Defenses
Swiss Cheese Model of Human Error
HUMAN FACTORS
Unsafe Acts
Routine Exceptional
ViolationsErrors
DecisionErrors
Skill-basedErrors
PerceptualErrors
Preconditionsfor Unsafe Acts
CommunicationCoordination
Planning
Fitness forDuty
Personal/Interpersonal
Factors
Condition ofOperators
AdverseMental States
AdversePhysiological
States
Physical/Mental
Limitations
PhysicalEnvironment
TechnologicalEnvironment
EnvironmentalFactors
Supervision
SupervisoryViolations
InadequateSupervision
PlannedInappropriate
Activities
Failed toCorrectProblem
OrganizationalInfluences
ResourceManagement
OrganizationalClimate
OperationalProcess
HUMAN FACTORS
Aviation
Military (Shappell & Wiegmann, 2004; Li et al., 2004; Li & Harris, 2006;
Guar,2005; Li & Harris, 2007; Gibb & Olsen, 2008; Pagan & de Voogt, 2008;
Paletz, 2009; Belland et al.,, 2010)
Commercial (Wiegmann & Shappell, 2001; Shappell et al., 2007; Li &
Harris, 2006; Li et al., 2008; Majumdar er al.,2009; Harris & Lee, 2011)
General Aviation (Wiegmann et al., 2005; Lenne et al., 2008; Dambier &
Hinkelbein, 2006; Guar, 2005; Lenné, et al., 2008; Li, Harris, & Yu, 2008 )
Unmanned Aerial Vehicles (Thompson, 2005; Tvaryanas,
Thompson, & Constable, 2006)
Aviation Maintenance (Krulak, 2004; Boquet et al., 2004; Rashid et
al., 2010)
Air Traffic Control (Scarborough, et al, 2005; Olsen & Shorrock, 2010)
Non-Aviation
Combat Operations (Jennings, 2008)
Construction (Garrett & Teizer, 2009)
Forensics (Wertheim, 2010)
Mining (Patterson et al., 2010)
Railway (Reinnach & Vaile, 2009; Baysari et al., 2008; Baysari et al., 2009)
Maritime (Winters & Valaitis, 2005; Celik & Cebi, 2009; Xi et al., 2009; Schröder-Hinrichs et al., 2011)
Medical (ElBardissi et al., 2007; Portalur, et al.., 2010)
Petrochemical (Koo et al., 2009)
Nuclear Power (Kim et al., 2008)
Expansion of HFACS
HUMAN FACTORS
Skill-based
Errors
Perceptual
Errors
Decision
Errors
ViolationsPe
rce
nta
ge
of A
ccid
en
ts
YearPercentages do not add up to 100%
General Aviation: Overall
HUMAN FACTORS
ERROR CATEGORY OVERALL SEMINAL
Frequency (%)
Fatal Non-fatal Total
Frequency (%)
Fatal Non-fatal Total
Directional Control 20 (0.50) 2018 (15.2) 2038 (11.8) 9 (0.57) 1326 (17.5) 1335 (14.6)
Airspeed 713 (17.9) 1127 (8.5) 1840 (10.6) 302 (19.2) 605 (8.0) 907 (9.9)
Stall/Spin 592 (14.9) 753 (5.7) 1345 (7.8) 84 (5.3) 144 (1.9) 228 (2.5)
Aircraft Control 654 (16.5) 665 (5.0) 1319 (7.6) 311 (19.8) 429 (5.7) 740 (8.1)
Compensation for winds 23 (0.6) 1046 (6.2) 1069 (6.2) 12 (0.8 859 (11.4) 871 (9.5)
General Aviation: Fine Grained Analysis(Skill-Based Errors)
HUMAN FACTORS
Number of
Cases Unsafe Act
Precondition
for Unsafe Act
Unsafe
Supervision
Organizational
Influence
Data Set n n (%) n (%) n (%) n (%)Chinese Military
Aviation325 325 (100%) 265 (81.54%) 159 (48.92%) 110 (33.85%)
Chinese Civil
Aviation35 35 (100%) 31 (88.57%) 28 (80.00%) 26 (74.29%)
Critical Cases 161 161 (100%) 73 (45.34%) 7 (4.35%) 12 (7.45%)
Entertainment 173 173 (100%) 107 (61.85%) 16 (9.25%) 2 (1.16%)
Food Services 328 328 (100%) 265 (80.79%) 123 (37.5%) 7 (2.13%)
Maintenance - Field 392 392 (100%) 161 (41.07%) 7 (1.79%) 14 (3.57%)
Maintenance - Site 87 87 (100%) 50 (57.47%) 9 (10.34%) 2 (2.30%)
Middle East Aviation 31 31 (100%) 20 (64.52%) 5 (16.13%) 4 (12.90%)
Mining - Australian 475 475 (100%) 380 (80.00%) 163 (34.32%) 43 (9.05%)
Mining - US 242 242 (100%) 216 (89.26%) 205 (84.71%) 128 (52.89%)
Remotely Piloted
Aircraft Operations48 48 (100%) 43 (89.58%) 22 (45.83%) 38 (79.17%)
US Commercial
Aviation - FAR 121143 143 (100%) 80 (55.94%) 14 (9.79%) 10 (6.99%)
US Commercial
Aviation - FAR 135779 779 (100%) 556 (71.37%) 26 (3.34%) 25 (3.21%)
US General Aviation -
FAR 13361 61 (100%) 26 (42.62%) 2 (3.28%) 0 (0.00%)
US General Aviation -
FAR 137761 761 (100%) 392 (51.51%) 2 (0.26%) 2 (0.26%)
US General Aviation -
FAR 9112516 12516 (100%) 7426 (59.33%) 477 (3.81%) 23 (0.18%)
US Gyroplane
Aviation158 158 (100%) 103 (65.19%) 4 (2.53%) 0 (0.00%)
-- 48.61% 1.91% 0.40%
-- 58.13% 7.95% 4.96%
-- 67.65% 14.00% 9.53%
HFACS Tier
Lower Confidence IntervalMean
Upper Confidence Interval
Benchmarking
HUMAN FACTORS
Associations Between Categories
Solid blue line – Significant Chi-Square, Odds Ratio,
and Lower Relative Risk
Dashed blue line – Significant Chi-Square and Odds
Ratio
Dashed orange line – Significant Chi-Square
HUMAN FACTORS
Solid blue line – Significant Chi-Square, Odds Ratio,
and Lower Relative Risk
Dashed blue line – Significant Chi-Square and Odds
Ratio
Dashed orange line – Significant Chi-Square
Associations – Tier Jumping
HUMAN FACTORS
Future Directions
Offshore Oil Drilling• Gulf of Mexico
Forensic Science• Latent Fingerprint Analyses
• Questioned Document Analyses
Medicine• Sentinel Events
• Cardiovascular OR