Prospective Gains in Safety and Cost Management; Using the HFACS to Proactively Address Organization Influences that Cause Human Error

Abstract: Created from the original work of James Reason’s Swiss Cheese accident causation model featuring human error and latent organizational influences, the Human Factors Analysis and Classification System (HFACS) has become a proven model for analysing human error in aviation accidents. HFACS classifies human error into four levels of organizational influence that can set the stage for unsafe acts to occur. In modern terms of Safety Management Systems (SMS) proactivity, however, the HFACS is still utilized largely as a reactive accident investigation tool, focused on analysis of historical events to form ideas about system deficiencies and negative trends. This study emphasizes that human error on the bottom portion of the HFACS model often carries a substantial monetary and human cost to the organization, even when an aircraft is not involved in a classified accident. Here, the researchers sought a more proactive and systematic way of pre-identifying latent negative organizational influences causing the costliest human errors and finding mitigating solutions by tapping into front line perspectives. This project began with the development of a strategic aviation leadership course for a commercial aviation organization, “Airline X,” with the intent of gathering qualitative data to systematically address HFACS organizational influences that could lead to costly human error accidents and incidents. Researchers proposed top-down, proactive mitigations based on an extensive thematic analysis of front-line perspectives on various safety threats and other organizational deficiencies. After a year of collecting data from over 1,100 individuals during the leadership course through the Airline X pilot group, the qualitative data was compiled and analysed from the responses to two short surveys; one was given early in the course after guided discussions, and the other at the end of the course. The qualitative methodology enabled categorization of the pilots’ answers into common themes. Ten sub-themes were established, all related to organizational influences, then prioritized, and superimposed on the HFACS. During the study, sub-themes related to ramp safety literally manifested themselves in the form of two costly ramp incidents that resulted in revenue loss, as both aircraft were temporarily removed from service for repair. In a display of prescient, timely feedback from the pilot group and supporting accident data showing the direct cost of a potentially failed ramp policy (organizational influences) as evidence, the researchers recommended a continuous cycle of ‘Bottom up (reactive), Top down (proactive)’ Human Factors Safety Management Systems (HFSMS) feedback to senior and middle management to enhance the company’s existing SMS.

Keywords: Latent Organizational Influences, Human Error, HFACS, Leadership Course, SMS

DOI: 10.54941/ahfe1005311

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