3A-Event Review Using HFACS Exercise Template

Date:______

Name:______

Instructions

Work in small groups (2 or 3 people / group).

Use the event description and the worksheets 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.

Event Details

PROVIDE DETAILS (JUST THE FACTS, NO OPINIONS) REGARDING THE EVENT

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)

Unsafe Acts

Errors
Skill-based Errors / Present?
Breakdown in visual scan
Omitted checklist item
Omitted step in a procedure
Over-reliance on automation
Failed to prioritize attention
Task overload
Negative habit
Failure to see and avoid
Distraction
Decision Errors / Present?
Inappropriate procedure
Knowledge of system/procedure Less Than Adequate (LTA)
Exceeded ability
Wrong response to emergency
Perceptual Errors / Present?
Due to visual illusion
Due to spatial disorientation
Violations
Routine / Present?
Inadequate briefing
Violated Rules, ARS, or OPP
Failed to comply with procedures
Exceptional / Present?
Performed unauthorized procedure
Exceeded limits
Accepted unnecessary hazard or risk
Not qualified to perform task
Comments for This Section (Unsafe Acts)

Preconditions of Unsafe Acts

Condition of Operator
Adverse Mental States / Present?
Loss of situation awareness
Complacency
Stress
Overconfidence
Task saturation
Alertness (drowsiness)
Get-home-itis
Mental fatigue
Circadian Dysrhythmia
Channelized attention
Adverse Physiological States / Present?
Medical illness
Physical fatigue
Intoxication
Effects of OTC medications
Physical/Mental Limitations / Present?
Visual limitations
Insufficient reaction time
Information overload
Inadequate experience for complexity of the situation
Incompatible physical capabilities
Lack of sensory input
Personnel Factors
Crew Resource Management / Present?
Failed to conduct adequate brief
Lack of teamwork
Lack of assertiveness
Poor communication
Personal Readiness / Present?
Failure to obtain adequate rest
Training Less Than Adequate (LTA)
Overexertion while off duty
Poor dietary practices
Pattern of poor risk judgment
Environmental Factors
Physical Environment / Present?
Lighting
Toxins/Allergens
Technological Environment / Present?
Display/Interface design
Checklist layout
Automation
Comments for This Section (Preconditions of Unsafe Acts)

Unsafe Supervision

Unsafe Supervision
Inadequate Supervision / Present?
Failed to provide proper training
Failed to provide guidance/oversight
Failed to provide adequate technical data and/or procedures
Failed to provide adequate rest period
Lack of accountability
Perceived lack of authority
Failed to track qualifications
Over-tasked/untrained supervisor
Loss of supervisory situation awareness
Planned Inappropriate Operations / Present?
Poor crew assignments
Failed to provide adequate brief time/supervision
Risk outweighs benefit
Excessive tasking/workload
Failed to Correct a Known Problem / Present?
Failed to identify and correct inappropriate/risky behavior
Failed to correct a safety hazard
Failed to initiate corrective action
Failed to report unsafe tendencies
Supervisory Violations / Present?
Authorized unqualified crew for duty
Failed to enforce rules and regulations
Violated procedures
Authorized unnecessary hazard
Willful disregard for authority by supervisors
Inadequate documentation
Fraudulent documentation
Comments for This Section (Unsafe Supervision)

Organizational Influences

Resource Management
Human Resources / Present?
Selection
Staffing/manning
Training
Background checks
Monetary/Budget Resources / Present?
Excessive cost cutting
Lack of funding
Equipment/Facility Resources / Present?
Poor equipment/facility design
Purchasing of unsuitable equipment
Failure to correct known design flaws
Organizational Climate
Structure / Present?
Chain-of-command
Communication
Accessibility of supervisor
Delegation of authority
Formal accountability for actions
Policies / Present?
Promotion
Hiring, firing, retention
Drugs and alcohol
Incident investigations
Culture / Present?
Norms and rules
Organizational customs
Values, beliefs, attitudes
Organizational Process
Operations / Present?
Operational tempo
Incentives
Quotas
Time pressure
Schedules
Procedures / Present?
Performance standards
Clearly defined objectives
Procedures/instructions about procedures
Oversight / Present?
Established safety program/risk management program
Management monitors and checks resources, climate, and processes
Comments for This Section (Organizational Influences)
Additional Thoughts Comments Regarding This Event
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