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Human Factors

Analysis and
Classification System
Organizational
(HFACS)
Factors
Unsafe
Supervision

PreConditions
for
Unsafe
Acts

Unsafe
Acts

Swiss Cheese Model

UNSAFE
UNSAFE
ACTS
ACTS

Violations

Errors
Errors

Skill-based
Errors

Decision
Errors

Perceptual
Errors

Unsaf
e
Acts

Routine

Exceptional

PRECONDITIONS
FOR
UNSAFE ACTS

Substandard
Substandard
Practices
Practicesof
of
Operators
Operators

Substandard
Substandard
Conditions
Conditionsof
of
Operators
Operators

Adverse
Adverse
Adverse
Adverse
Physiological
Physiological
Mental
MentalStates
States
States
States

Physical/
Physical/
Mental
Mental
Limitations
Limitations

Crew
Non-Supervisory
Crew
Non-Supervisory
Resource
Tolerance
Resource
Toleranceof
of
Management
Unsafe
Acts
Management
Unsafe Acts

Preconditions
for
Unsafe Acts
Unsafe
Acts

Personal
Personal
Readiness
Readiness

UNSAFE
UNSAFE
SUPERVISION
SUPERVISION

Unforeseen
Unforeseen

Unrecognized
Unrecognized
Hazardous
Hazardous
Operations
Operations

Inadequate
Inadequate
Documentation/
Documentation/
Procedures
Procedures

Known
Known

Inadequate
Inadequate
Supervision
Supervision

Planned
Planned
Inappropriate
Inappropriate
Operations
Operations

Unsafe
Supervision
Preconditions
for
Unsafe Acts
Unsafe
Acts

Failure
Failureto
to
Correct
Correct
Problem
Problem

Supervisory
Supervisory
Violations
Violations

ORGANIZATIONAL
INFLUENCES

Resource
Resource
Management
Management

Organizational
Climate

Operational
Process

Organizational
Influences
Unsafe
Supervision

Preconditions
for
Unsafe Acts
Unsafe
Acts

Human Factors
ProvidesAnalysis
More than just an
Accident Investigation Tool
Organizational
Factors

Unsafe
Supervision

Opportunity for
Pro-active Action
by Management

Preconditions
for
Unsafe Acts

Failures in your
Systems Defenses

Unsafe
Acts

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