The HFACS Framework
Case Studies
The Implementation of HFACS: One Organization's Journey Towards Improving Safety
The Problem
With the increase of technology over the last hundred years, the role of humans within industry has changed. Gone are the days in mining history where workers were sent into holes with a pickaxe and left for hours performing manual labor. Today's mining industry has moved away from manual labor. Instead, the primary task of workers is to operate equipment usually from within the somewhat comfort of a cab. While the safety risk associated with mining has decreased, injury and fatality rates remain some of the highest in the worl. Some have attributed the increased risk associated with mining to the variety of adverse working conditions miners are exposed to. While these conditions do play a role, the majority of accidents cannot be solely attributed to adverse working conditions. In fact, a study by the U.S. Bureau of Mines found that nearly 85% of all mining accidents identified human error as a causal factor. Clearly, if human error is such a reoccurring problem, the identification and elimination of these errors is worth pursuing.
The Solution
In an effort to reduce injury and accident rates and improve safety across mine sites, one mining organization set out to identify and reduce instances of human error. To accomplish this, the Department of Mines and Energy (DME), in Queensland, Australia under the guidance of a member of HFACS, Inc. set out to implement HFACS as part of the safety management system for all mines in the state. Reducing human error is not an overnight process. In fact, it took DME over a year to create a safety system in which human error causes are identified and analyzed.
The first step in implementing the HFACS framework into the already existing safety system was to modify the framework to meet the needs of the organization. This included developing nanocodes, or examples, of typical human error and upstream causes that fell under each causal category. The final framework, HFACS-MI, incorporates the needs of DME and provides a theoretically proven investigation and analysis framework.
DME then began to identify human error causal factors. This was done through the analysis of historical data obtained from mine sites throughout the state. This analysis utilized the HFACS-MI framework to classify human error causal factors in a systematic way. In total, DME analyzed over 500 accident cases from a 5-year time span. Results showed that unsafe acts of the operator, the lowest tier of the HFACS framework, were present in almost 95% of all cases. When the analysis of all causal categories was preformed, it became evident that fewer causal factors were identified at the higher tiers, pointing to not good supervision and organizational oversight, but a failure to collect data regarding these tiers. Although these results were not abnormal, steps needed to be taken to ensure that investigations focused efforts on these higher tiers. After all, addressing problems further upstream have a larger impact on improving safety.
Through the use of the HFACS-MI framework, DME was able to identify areas of human error and system deficiencies. By taking these steps to improve safety, DME is hoping to reduce the number and frequency of incidents and accidents. As this organization has shown, improvements in safety cannot happen overnight, but the benefits of investing in safety are immeasurable.
