Bushra Griffith
The Swiss Cheese model is a framework used to analyse accidents and adverse events in complex systems. It was developed by James Reason in 1990 and likens human systems to multiple slices of Swiss cheese, with holes of varying sizes representing weaknesses in individual parts of the system. The model has been widely adopted across various fields, including aviation, healthcare, transportation and cybersecurity. However, it has also faced criticism for its broad application and lack of supporting models. The Human Factors Analysis and Classification System (HFACS) expands on the Swiss Cheese model by breaking down the barriers into a taxonomy of reportable accident causation characteristics. This enables organisations to collate data and identify trends over time, working backwards from an accident to identify active and latent failures within the organisation. The goal of HFACS is to understand the underlying causal factors of an accident rather than attributing blame, ultimately improving human performance and reducing accident rates.
| Characteristics | Values |
|---|---|
| Basis | James Reason's Swiss Cheese Model |
| Modelling | Shares barriers with the Swiss Cheese Model, but breaks them down further into a taxonomy |
| Proactivity | Can be used to identify historical hazards and proactively prevent them |
| Accident Causation | Identifies human error at four levels of failure: unsafe acts, preconditions for unsafe acts, unsafe supervision, and organisational influence |
| Accident Investigation | Can be used as a guide to systematically identify active and latent failures within an organisation |
| Goal | To understand the underlying causal factors that lead to an accident, rather than to attribute blame |
| Applications | Mining, construction, rail, healthcare, aviation, cybersecurity, public health |
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What You'll Learn
- HFACS identifies human error at four levels of failure
- It breaks down barriers into a taxonomy of reportable accident causation characteristics
- It can be used to identify where interventions are needed
- It helps to formulate trends over time
- It can be used to improve human performance and decrease accident and injury rates
HFACS identifies human error at four levels of failure
The Human Factors Analysis and Classification System (HFACS) is a tool for analysing human factors issues associated with accidents. It was developed by Dr. Scott Shappell of the Civil Aviation Medical Institute and Dr. Doug Wiegmann of the University of Illinois at Urbana-Campaign. The framework is based on James Reason's Swiss Cheese model, which identifies four levels of human failure:
Unsafe Acts
This level focuses on the immediate actions that directly contribute to an accident. These are the unsafe behaviours or actions of individuals that occur during the performance of a task. Examples include incorrect actions, errors of omission, or violations of procedures or rules.
Preconditions for Unsafe Acts
This level considers the factors that increase the likelihood of unsafe acts occurring. These are conditions or influences that affect an individual's ability to perform a task safely. Examples include fatigue, stress, inadequate training, or distractions.
Unsafe Supervision
This level addresses the role of supervisors or managers in creating an environment that allows unsafe acts to occur. It includes factors such as inadequate supervision, failure to provide proper training, or ineffective communication of safety procedures.
Organisational Influences
The final level looks at the broader organisational factors that can contribute to accidents. This includes issues such as inadequate safety policies, poor safety culture, or organisational pressures that may compromise safety.
By breaking down the causes of accidents into these four levels, HFACS provides a comprehensive framework for understanding and addressing human error. It allows organisations to identify breakdowns within their systems, analyse historical data, and implement targeted interventions to improve human performance and reduce accident rates.
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It breaks down barriers into a taxonomy of reportable accident causation characteristics
The Swiss Cheese Model, developed by James Reason, is a visual framework used to analyse accidents and adverse events in complex systems. It illustrates how accidents occur when multiple layers of defence, represented as slices of Swiss cheese, align through holes. These holes symbolise various failures or unsafe conditions.
The Human Factors Analysis and Classification System (HFACS) is heavily based on the Swiss Cheese Model. It identifies human error at four levels of failure: unsafe acts of operators, preconditions for unsafe acts, unsafe supervision, and organisational influences. The HFACS framework breaks down the barriers of the Swiss Cheese Model into a taxonomy of reportable accident causation characteristics.
The taxonomy enables an organisation to collate reportable data and formulate trends over time. By using HFACS, an organisation can identify where hazards have historically arisen and start to prevent them, leading to improved human performance and decreased accident and injury rates.
Working back from the accident, HFACS breaks each of Reason's levels into further accident causation types, forming a taxonomy between "errors and violations" for level 1, "sub-standard conditions of operators and substandard practices of operators" for level 2, "unsafe supervision" for level 3, and "organisational influences" for level 4.
The key similarity between the Swiss Cheese Model and HFACS is the inability to quantify data. However, HFACS provides a more comprehensive tool for identifying and classifying the human causes of accidents, bridging the gap between theory and practice.
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It can be used to identify where interventions are needed
The Human Factors Analysis and Classification System (HFACS) is a useful tool for identifying where interventions are needed to improve safety and prevent accidents. It achieves this by identifying the human causes of accidents and offering tools for analysis, allowing organisations to proactively address hazards.
The HFACS framework was developed by Scott Shappell and Doug Wiegmann in response to data showing that human error was a primary causal factor in 80% of flight accidents in the Navy and Marine Corps. It expands on James Reason's Swiss Cheese model of accident causation, which identifies four levels of barriers or defences against accidents: organisational influences, unsafe supervision, preconditions for unsafe acts, and unsafe acts.
Reason's Swiss Cheese model is a widely accepted visual framework that likens an organisation's defences against failure to slices of Swiss cheese with holes of varying sizes and positions. The holes represent weaknesses in the system, and accidents occur when the holes momentarily align, creating a "trajectory of accident opportunity". The model promotes a systems-oriented approach, encouraging investigators to look beyond individual errors to the underlying processes and systemic vulnerabilities within organisations.
While the Swiss Cheese model is a useful tool for understanding accidents retrospectively, HFACS goes further by providing a comprehensive framework for identifying and classifying the human causes of accidents. It breaks down Reason's levels into further accident causation types, forming a taxonomy between errors and violations, sub-standard conditions and practices of operators, unsafe supervision, and organisational influences. This taxonomy enables organisations to collate reportable data and identify trends over time, allowing them to proactively address hazards and improve safety.
By using HFACS, organisations can identify where hazards have historically arisen and start to implement preventive measures. This proactive approach has been successfully applied in various industries, including mining, construction, rail, and healthcare, demonstrating its versatility and effectiveness in enhancing safety and reducing accident and injury rates.
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It helps to formulate trends over time
The Human Factors Analysis and Classification System (HFACS) is a framework that identifies human error at four levels of failure: unsafe acts of operators, preconditions for unsafe acts, unsafe supervision, and organisational influence. It was developed by Scott Shappell and Doug Wiegmann in the early 2000s and is heavily based on James Reason's Swiss Cheese Model.
The Swiss Cheese Model is a visual framework used to analyse accidents and adverse events in complex systems. It illustrates how accidents occur when multiple layers of defence, represented as slices of Swiss cheese, align through holes. These holes symbolise various failures or unsafe conditions, which can randomly open and close.
One of the improvements that HFACS offers over the Swiss Cheese Model is its ability to help organisations formulate trends over time. While the Swiss Cheese Model is a useful tool for understanding how accidents occur, it does not provide a clear framework for collecting and analysing data over time.
On the other hand, HFACS breaks down the barriers of the Swiss Cheese Model into a taxonomy, which enables organisations to collate reportable data and identify trends. By using HFACS, organisations can identify where hazards have historically arisen and start to implement preventive measures. This helps to improve human performance and decrease accident and injury rates.
For example, in the context of aviation, HFACS can be used to identify the human causes of accidents and plan preventive training. This proactive approach helps to address the underlying causal factors that lead to accidents, rather than simply reacting to incidents after they have occurred.
Overall, the ability of HFACS to help organisations formulate trends and take proactive measures based on data analysis is a significant improvement over the Swiss Cheese Model, contributing to enhanced safety and risk management.
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It can be used to improve human performance and decrease accident and injury rates
The Human Factors Analysis and Classification System (HFACS) is a framework that identifies human error at four levels of failure: unsafe acts of operators, preconditions for unsafe acts, unsafe supervision, and organisational influences. It is based on the Swiss Cheese model of accident causation, developed by Dr James Reason, which views human error as a symptom of a larger problem in an organisation, rather than the cause of an accident.
The Swiss Cheese model is a visual framework used to analyse accidents and adverse events in complex systems. It illustrates how accidents occur when multiple layers of defence, represented as slices of Swiss cheese, align through holes. These holes symbolise various failures or unsafe conditions. The model promotes a systems-oriented approach to safety, urging investigators to look beyond individual errors to the underlying processes within organisations.
The HFACS framework expands on the Swiss Cheese model, breaking down each of Reason's levels into further accident causation types and forming a taxonomy between errors and violations, sub-standard conditions and practices of operators, unsafe supervision, and organisational influences. This taxonomy enables organisations to collate reportable data and formulate trends over time.
By using the HFACS framework, organisations can identify where hazards have historically arisen and start to prevent them, leading to improved human performance and decreased accident and injury rates. Accident investigators can systematically identify active and latent failures within an organisation that culminated in an accident. The goal of HFACS is to understand the underlying causal factors that lead to an accident, rather than to attribute blame.
The HFACS framework has seen remarkable success in a variety of industries, including mining, construction, rail, and healthcare. It provides investigators with a comprehensive, user-friendly tool for identifying and classifying the human causes of accidents and offers tools for analysis as a way to plan preventive training.
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Frequently asked questions
The Swiss Cheese Model is a visual framework used to analyse accidents and adverse events in complex systems, such as healthcare and aviation. It illustrates how accidents occur when multiple layers of defence, represented as slices of Swiss cheese, align through holes.
The Human Factors Analysis and Classification System (HFACS) identifies human error at four levels of failure: unsafe acts of operators, preconditions for unsafe acts, unsafe supervision, and organisational influences. It was developed by Scott Shappell and Doug Wiegmann in the early 2000s, based on the Swiss Cheese Model.
While the Swiss Cheese Model identifies the barriers that organisations should have in place to prevent accidents, HFACS breaks these down further into a taxonomy of reportable accident causation characteristics. This enables organisations to collate reportable data and formulate trends over time, allowing them to identify where interventions are needed to prevent future accidents.
HFACS has seen remarkable success in a variety of industries, including mining, construction, rail, and healthcare. The first successful use of the framework occurred in the US Navy, where it was developed in response to a high rate of human error as a primary causal factor in flight accidents.
