A Practical Guide to Human Factors Analysis and Classification System (HFACS) 7.0

A Practical Guide to Human Factors Analysis and Classification System (HFACS) 7.0

By Chuan HE

Copyright 2020 Chuan HE

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If there is a wrong way to do it, that is the way you will do it.

- Murphy's Law

Preface

It has been repeatedly found again and again that human error is partially responsible for accidents of complex systems, and human errors turned out to be the primary contributing cause for about 80% to 90% of the accidents in complex and high risk systems, such as nuclear power plants, aviation, gas and oil, medical domains, etc. Safety research shows that human error is a major cause of industrial and transportation accidents, as opposed to mechanical failures. For example, statistic data shows that more than 80% of the US Naval aviation accidents are caused mainly by human errors.

To analyze the accidents and identify the underlying causes, many human factor models, or frameworks, have been designed and applied. The human factor model serves as a tool to provide a measurement standard to categorize the human errors, allowing deep dive into the accident event rebuild especially with human interactions, and eventually identifying the root cause of the human factors for the accidents. The root cause collection and accurate analysis of human factors provides valuable information and guidance for improvement of the safety and robustness of system designs, operation manuals, protocols, training designs, and maintenance procedures.

However, textual reports are difficult for human beings to analyze and understand, thus it makes sense to use standardized classification codings. This will enable the development of a safety database for people to efficiently analyze the information, to search for patterns, similarities, and trends among accidents. The resulting analysis can be valuable not only in the development of data driven safety interventions and mitigation strategies, but also in evaluating their effectiveness.

Learning is the key to prevent future similar accidents by human mistakes. A learning theory is described as a body of principles given by psychologists and educators to explain how people acquire skills, knowledge, and attitudes. Various learning theories are used in training programs helping to improve and accelerate the learning process. Key concepts such as desired learning outcomes, objectives of the training, and depth of training.

Many theories have been created over the years attempting to explain how people learn. Even though not all people agree, most do agree that learning may be explained by a combination of two approaches: behaviorism and the cognitive theories.

Behaviorism

Behaviorism believes that animals and humans learn in the similar way, stressing the importance of having a particular form of behavior reinforced by someone to shape or control what is learned. With behaviorism instructors manipulate students with stimuli, induce the desired behavior or response, and reinforce the behavior with appropriate rewards. In general, it emphasizes positive reinforcement rather than no reinforcement or punishment. Other features of behaviorism are considerably more complex than this simple explanation.

Cognitive theory

Cognitive theory focuses on what is going on inside people's mind. Learning is not just a change in behavior; it is a change in the way a student thinks, understands, or feels. There are several branches of cognitive theory, and two of them are the information processing model and the social interaction model.

A good human factor analysis system shall contain four critical elements: reporting, just, flexible, and learning culture. However, under-reporting, incomplete recordings, and insufficient conditions and contexts description are common to many accident reporting systems, that commonly failed to show a complete picture of the accidents. To enable learning, it is a must to collect reliable and accurate human factors data to avoid future similar accidents.

One such model, which is commonly seen as a good reporting system, and which is widely used in aviation and other industries, is the HFACS, Human Factors Analysis and Classification System. It is a comprehensive accident investigation and analysis tool with focuses both on the act of the individual preceding the accident, and on other contributing factors in the system.

In this book, we introduce Human Factor in Chapter 1, HFACS 7.0 content in Chapter 2, and practical human factor analysis examples for aviation accidents using HFACS 7.0 in Chapter 3.

Chapter 1. Human Factor

Industrial facilities and plants continuously experience incidents and accidents, specifically during their construction and operation phases. Medical, road vehicle, aviation industries all have the same situation.

According to National Safety Council (2011), estimated total costs of industrial accidents in 2009 were around $168.9 billion, including:

- wage and productivity loss ($82.4 billion)

- medical ($38.3 billion)

- administrative ($33.1 billion)

- motor vehicle damage ($2 billion)

- employers' uninsured costs ($10.3 billion)

- and fire loss costs ($2.8 billion)

In US 2011, industrial accidents caused approximately 3,600 fatalities and 5.1 million disabling injuries in industrial facilities and plants, which means on average a death rate of 1 every 2.5 hours and an injury rate of 1 every 6 seconds.

During a 14-year study period, NTSB recorded a total of 371 major airline crashes, 1,735 commuter/air taxi crashes, and 29,798 general aviation crashes. Sequence-of-events data linkage were available for 329 (89%) of the major airline crashes, 1,627 (94%) of the commuter/air taxi crashes, and 27,935 (94%) of the general aviation crashes. Crashes without the sequence-of-events data were significantly more likely than crashes with the sequence-of-events data to have occurred away from airports and to have involved less experienced pilots. However, these two groups of crashes have similar compositions of pilot age and gender, time of crash, type of aircraft, and basic weather conditions.

The study shows results as below:

At the bivariate level, several pilot characteristics were significantly associated with pilot error in general aviation crashes and commuter/air taxi crashes. Of the general aviation crashes involving pilots under age 20, 94% were attributed to pilot error, compared with about 85% of general aviation crashes involving older pilots (p < 0.001). Age-related variation in the prevalence rates of pilot error was statistically insignificant for major airline crashes and commuter/air taxi crashes.

Total flight time showed an effect on pilot error only in general aviation crashes, with the prevalence rate decreasing progressively from 91% for pilots in the lowest quartile to 79% in the highest quartile (p < 0.001). A further examination revealed that the protective effect of total flight time against pilot error existed only in general aviation crashes under visual meteorological conditions (VMC).

General aviation crashes involving student/private pilots were more likely to be attributed to pilot error than other general aviation crashes. A lower prevalence of pilot error was also observed in commuter / air taxi crashes involving pilots who held airline transport certificates, as compared with commuter/air taxi crashes involving commercial pilots.

Female pilots accounted for 0.3% of major airline crashes, 3% of commuter/air taxi crashes, and 4% of general aviation crashes. Partly reflecting the effect of lesser flight experience, a higher proportion of general aviation crashes and commuter/air taxi crashes involving female pilots were caused by pilot error than those involving female pilots. Female pilots who were involved in general aviation crashes recorded an average 888 total flight hours (SD 2,845 h), compared with 2,411 h (SD 4,426 h) for their male counterparts (p < 0.001). A striking gender discrepancy in total flight time also existed among pilots who were involved in commuter/ air taxi crashes [mean total flight time: 5,795 h (SD 4,891 h) for males and 3,257 h (SD 2,269) for females, p < 0.001].

With regard to crash circumstances, instrument meteorological conditions (IMC) were associated with a significantly higher prevalence of pilot error, irrespective of the type of flight operations. An elevated prevalence of pilot error was found in major airline crashes and general aviation crashes occurring on airports, as compared with crashes away from airports. Whereas the proportion (40%) of major airline crashes that occurred at nighttime (6 pm to 5:59 a.m.) was considerably higher than that for commuter/ air taxi crashes (33%) and for general aviation crashes (22%), the prevalence of pilot error was similar between daytime and nighttime crashes in each of the three aviation categories.

Helicopters constituted 18% of commuter/air taxi crashes and 6% of general aviation crashes; and pilot error was less prevalent in helicopter crashes than in airplane crashes. More than half (53%) of the fatal major airline crashes were attributed to pilot error, compared with 36% of the nonfatal major airline crashes (p = 0.03). The prevalence of pilot error was also significantly higher in fatal commuter/air taxi crashes and fatal general aviation crashes.

Chapter 1.1. Accident Causes

To analyze the causes of accidents, need to consider interactions between four factors: technical, environmental, organizational, and human factor.

Technical factor is most studied, and receives the most focus by researches, resulting with many theories and practices deployed to safety critical systems which reduces system failures significantly, eg. diagnostic technology, redundancy and backup design, robustness and fault tolerant controls. It has a focus on equipment malfunction and failure caused by random failure or design flaws, with the nature that the system no longer meets its designed specifications and could not provide the designed functionalities any more. In many cases, the system failures also lead to stressful or confusing situations for human controllers which finally results in improper, insufficient, untimely or incorrect human responses that eventfully develop as catastrophes.

Environmental factors involve the physical surroundings of the operators or equipment which could affect performance, eg. weather conditions, noise, and illumination. The analysis of General Aviation (GA) databases from 2003 to 2007 shows that of 8,657 aviation accidents, 1,740 were weather related either as the primary cause or as a contributing factor.

Organizational factors are about inadequate procedures and training, insufficient standards / requirements / processes, and company / management induced pressure. For aviation industry, the Chief Pilot very