event review using hfacs (template) instructor(s) name(s) date
TRANSCRIPT
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Event Review Using HFACS(Template)
Instructor(s) Name(s)
Date
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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.
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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)
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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.
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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