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Accident Investigation Guide: 2005 Edition

Exhibit 2-2

Human Factors Accident and Incident Analysis

Sensory and Perceptual Factors

• Misjudgment of distance, clearance, speed, and so forth
  
  
• False perception caused by visual illusion. Conditions that impair visual performance:
  • Featureless terrain (such as a desert, dry lake, water, snow).
  • Darkness and poor visibility.
  • Smoke and changing smoke patterns.
  • Mountainous terrain or sloping runway.
  • Anomalous light effects that cause flicker vertigo.
  • Low contrast of objects to background or poor illumination.
  • View into bright sunlight or moonlight.
  • Shadows.
  • Whiteout snow conditions.
    
    
• Spatial disorientation and vertigo. Conditions that affect sense of body position:
  • Loss of visual cues.
  • Adverse medical condition or physiological condition (alcohol and drug effects, hangover, dehydration, fatigue, and so forth).
  • Moving head up and down, looking in and out to change radios, answering or using cell phones.
    
    
• Loss of situational awareness. Types:
  • Geographic disorientation (such as deviation from route, loss of position awareness).
  • General loss of situational awareness (such as failure to perceive hazardous condition).
  • Erroneous situational assessment (misinterpretation of situation or condition).
  • Failure to predict or anticipate changing conditions.
  • False hypothesis confirmation bias (persistent false perception or misconception of situation).
    
    
• Attention failure (such as failure to monitor or respond when correct information is available). Types:
  • Failure to visually scan outside the vehicle or equipment for hazards.
  • Omission of checklist items.
  • Failure to respond to communication or warning.
  • Control-action error:
    • Failure to set, move, or reset control switch (lapse).
    • Unintentional activation of control switch (slip).
    • Control-substitution error (slip).
    • Control-reversal error (slip).
    • Control-adjustment or precision error (slip).
      
      
• Conditions that affect attention and situational awareness:
  • Inattention (focus on information unrelated to tasks).
  • Channelization, fixation (psychological narrowing of perception).
  • Distraction (preoccupation with internal [mental] event or with external event).
  • Task overload due to systems (such as communications).
  • Task overload due to equipment systems assignment factors.
  • Cognitive workload (problem-solving concentration or information overload).
  • Habit influence or interference.
  • Excessive crew stress or fatigue.
  • Excessive workload or tasking.
  • Inadequate briefing or preparation.
  • Inadequate training or experience for assignment.
  • Negative learning transfer (such as during transition to new assignment).
  • Adverse meteorological conditions.
  • Tactical-situation overload or display-information overload.
  • Inadequate crew motivation or inadequate vigilance.
  • Inadequate equipment design.

Medical and Physiological Factors

• Carbon monoxide poisoning.
• Self-medication (without medical advice or against medical advice).
• Motion sickness.
• Incompatible physical capabilities.
• Overexertion while off duty.
• Influence of drugs or alcohol.
• Cold or flu (or other known illness).
• Excessive personal stress or fatigue.
• Inadequate nutrition (such as omitted meals).
• Hypoxia.
• Heat.
• Cold.
• Stress induced by heightened state of alertness.
• Affects of smoke.
• Dehydration.
  
  
• Other medical or physiological condition.
  • Assignment tasking or job fatigue (such as being on duty more than 14 hours, late-night or early-morning operations).
  • Cumulative fatigue (such as excessive physical or mental workload, circadian disruption, or sleep loss).
  • Cumulative effects of personal or occupational stress (beyond stress-coping limit).
  • Emergency condition or workload transition (from normal operation to emergency operation).
  • Medical or physiological preconditions (health and fitness, hangover, dehydration, and so forth).

Knowledge and Skill Factors

• Inadequate knowledge of systems, procedures, and so forth (knowledge-based errors). Types:
  • Knowledge-based.
  • Inadequate knowledge of systems, procedures.
  • Used improper procedure.
  • Ill-structured decisions.
  • Failure in problem solving.
    
    
• Inadequate equipment control, or inadequate accuracy and precision of equipment maneuvering (skill-based error). Types:
  • Breakdown in visual scan.
  • Failure to see and avoid.
  • Over or under reacting.
  • Over or under controlling.
  • Inadequate experience for complexity of assignment.
    
    
• Misuse of procedures or incorrect performance tasks (rule-based error), such as:
  • Failure to perform required procedure.
  • Use of wrong procedure or rule(s).
  • Failure to conduct step(s) in prescribed sequence.
    
    
• Conditions that lead to inadequate operational performance:
  • Lack or variation of standards.
  • Loss of situational awareness in varying environment.
  • Demonstration of performance below required profi-ciency standards or current standards.
  • Demonstration of inadequate performance or documented deficiencies.
  • Inadequate essential training for specific task(s).
  • Inadequate recent experience or inadequate experience.
  • Lack of sensory input.
  • Limited reaction time.

Assignment Factors

• Failure of dispatch to provide correct critical information (such as frequencies, location, other equipment, or resources).
• Poor communication with other assets (such as ground or aircraft).
• Inadequate or faulty supervision from ground or tactical aircraft.
• Lack or variation of standards.
• Nonparticipant or noncommunicative equipment or resources at the scene.
• Loss of situational awareness in varying environment.
• Changing plans or tactics (change of teams on incidents).
• Unanticipated change of radio frequencies.
• Intentional deviation from procedures.
• Unintentional deviation from procedures.
• Demonstration of performance below required proficiency standards or current standards.
• Demonstration of inadequate performance or documented deficiencies.
• Inadequate essential training for specific task(s).
• Inadequate recent experience or inadequate experience for assignment.
• Transition (learning new equipment or operational systems).
• Inadequate knowledge of tactical situation.
• Lack of sensory input.
• Limited reaction time.
  
  
• Conditions that lead to inadequate assignment performance.
  • Smoke.
  • Wind shifts.
  • Changes in fire behavior.
  • Low visibility.
  • Unexpected equipment, resources, or aircraft.
  • Assignment intensity.
  • Assignment creep.
  • Assignment urgency.
  • Failure to recognize deteriorating conditions.
  • Time compression.
  • Diverts to new incidents.
  • Excessive communication demands.
  • Past assignment success based on high-risk behavior.

Personality and Safety Attitude

• Overconfidence.
• Excessive motivation to achieve assignment.
• Reckless operation.
• Anger or frustration on the job.
• Stress-coping failure (such as anger).
• Overly assertive or nonassertive.
• Inadequate confidence to perform tasks or activities.
• Acquiescence to social pressure (from organization or peers) to operate in hazardous situation or condition.
• Failure to report or act upon incidents of misconduct.
• Toleration of unsafe acts and behaviors.
• Poor equipment or assignment preparation.

Judgment and Risk Decision

• Acceptance of a high-risk situation or assignment.
• Misjudgment of assignment risks (complacency).
• Failure to monitor assignment progress or conditions (complacency).
• Use of incorrect task priorities.
• Intentional deviation from safe procedure (imprudence).
  
  
• Intentional violation of standard operating procedure or regulation. Types:
  • Violation of orders, regulations, standard operating procedures (SOP).
  • Crew rest requirements.
  • Inadequate training.
  • Violated agency policy or contract.
  • Failed to comply with agency manuals.
  • Supervisor knowingly accepted unqualified crew.
  • Failed to obtain valid weather brief.
  • Accepted unnecessary hazard.
  • Lacks adequate of up-to-date qualifications for assignment.
    
    
• Intentional disregard of warnings.
• Noncompliance with personal limits.
• Noncompliance with published equipment limits.
• Noncompliance with prescribed assignment parameters.
• Acquiescence to social pressure (from organization or peers).
  
  
• Conditions leading to poor safety attitude and risky judgment:
  • History of taking high risks (personality-driven).
  • Pattern of overconfidence.
  • Personal denial of wrongdoing.
  • Documented history of marginal performance or failure.
  • Excessive motivation (did not know limits).
  • Reputation as a reckless individual.
  • Failure to cope with life stress (anger or frustration).
  • Overly assertive or nonassertive (interpersonal style).
  • Influenced by inadequate organizational climate or safety culture (such as lack of adequate supervision).

Communication and Crew Coordination

• Inadequate assignment plan or brief.
• Inadequate or wrong assignment information conveyed to crew (dispatch or supervisor errors).
• Failure to communicate plan or intentions.
• Failure to use standard or accepted terminology.
• Failure to work as a team.
• Inability or failure to contact and coordinate with ground or aviation personnel.
• Inadequate understanding of communication or failure to acknowledge communication.
• Interpersonal conflict or crew argument during assignment.
  
  
• Conditions leading to inadequate communication or coordination:
  • Inadequate training in communication or crew coordination.
  • Inadequate standard operating procedures for use of crew resources.
  • Inadequate support from organization for crewcoordination doctrine.
  • Failure of organizational safety culture to support crew resource management.

System Design and Operation Factors

• Use of wrong switch, lever, or control.
• Misinterpretation of instrument indication.
• Inability to reach or see control.
• Inability to see or interpret instrument or indicator.
• Failure to respond to warning.
• Selection or use of incorrect system-operating mode (mode confusion).
• Overreliance on automated system (automation complacency).
  
  
• Conditions that contribute to design-induced crew errors:
  • Inadequate primary equipment control or display arrangement.
  • Inadequate primary display data or data format.
  • Inadequate hazard advisory or warning display.
  • Inadequate system instructions or documentation.
  • Inadequate system support or facilities.
  • Inappropriate type or level of automation, or excessive mode complexity.

Supervisory and Organizational Factors

• Not adhering to rules and regulations.
• Inappropriate scheduling or crew assignment.
• Failure to monitor crew rest or duty requirements.
• Failure to establish adequate standards.
• Failure to provide adequate briefing for assignment.
• Failure to provide proper training.
• Lack of professional guidance.
• Undermining or failure to support crews.
• Failure to monitor compliance with standards.
• Failure to monitor crew training or qualifications.
• Failure to identify or remove a known high-risk employee.
• Failure to correct inappropriate behavior.
• Failure to correct a safety hazard.
• Failure to establish or monitor quality standards.
• Failure of standards, either poorly written, highly interpretable, or conflicting.
• Risk outweighs benefit.
• Poor crew pairing.
• Excessive assignment tasking or workload.
• Inadequate assignment briefing or supervision.
• Intentional violation of a standard or regulation.
  
  
• Failure to perceive or to assess (correctly) assignment risks, with respect to:
  • Unseen or unrecognized hazards.
  • Environmental hazards or operating conditions.
  • Assignment tasking and crew skill level.
  • Equipment limitations.
    
    
• Conditions leading to supervisory failures:
  • Excessive operations or organizational workload (imposed by the organization or imposed by organizational chain).
  • Inadequate organizational safety culture.
  • Supervisor is over-tasked.
  • Supervisor is untrained.
  • Inattention to safety management (inadequate safety supervision).
  • Inadequate work standards or low performance expectations.
  • Inadequate or poor example set by supervisors.
  • Inadequate safety commitment or emphasis by supervisors.
  • Organization lacks an adequate system for monitoring and correcting hazardous conditions.
  • Supervisors fail to promote and reward safe behavior or quickly correct unsafe behavior.
  • Organization lacks adequate policies and procedures to ensure high quality work performance.
  • Organization lacks adequate job-qualification standards or training program.
  • Organization lacks adequate internal communication.
  • Organization had no system or an inadequate system for management of high-risk employees. Organization lacks adequate process or procedures for operational risk management.
  • Organization fails to provide adequate human factors training.
  • Organization fails to ensure sufficient involvement of medical and occupational health specialists.
  • Organization fails to establish or enforce acceptable medical or health standards.

Maintenance

• Procedures.
  • Unwritten.
  • Unclear, undefined, or vague.
  • Not followed.
    
    
• Records.
  • Discrepancies entered but not deferred or cleared.
  • Entries not recorded or not recorded in correct book(s).
  • Improper entries or unauthorized signature or number.
  • Falsification of entries.
    
    
• Publications, manuals, guides.
  • Not current.
  • Were unused for the procedure.
  • Incorrect manual or guide used for procedure.
  • Not available.
    
    
• Training.
  • Not trained on procedure.
  • Training not documented.
  • Falsified.
  • Not current.
    
    
• Personnel.
  • Not properly licensed.
  • Insufficient (staffing).
  • Improper or insufficient oversight.
  • Not properly rested.
    
    
• Management.
  • Nonexistent.
  • Ineffective.
  • Understaffed.
  • Ineffective organization of assigned personnel.
  • Insufficiently trained.
    
    
• Quality assurance.
  • Nonexistent.
  • Insufficiently trained.
  • Ineffective.
  • Not used when available.
    
    
• Inspection guides.
  • Unavailable.
  • Procedures not followed.
  • Insufficient.
  • Not current.
  • Not approved.
  • Not signed off.
  • Falsified.
  • Unapproved signature or number.
    
    
• Tools or equipment.
  • Improper use or procedure.
  • Uncalibrated.
  • Used improperly.
  • Not trained for the special equipment or tool.
  • Not used.
  • No tool control program.

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since July 21, 2005