Steven Cooke - Getting to Effective Solutions Instead of Blame - HFACS

Document created by Steven Cooke on Jun 9, 2017
Version 1Show Document
  • View in full screen mode

  Publication Details (including relevant citation   information):

  Presented in 2014 at ADIPEC, Abu Dhabi, UAE.


  Effective corrective action has always   depending on the correct and accurate identification of the real   problem to be fixed. Investigation of system deficiencies and   development of corrective action processes have evolved over the   decades from “experience-based” expert teams (internal or   external) to formalized methodologies than can be applied with a   basis of training and moderate field experience. All formal   Quality Management Systems (ISO-9001, ISO/TS 16949, AS 9100, Six   Sigma) outline requirements for both correct investigation and   documented corrective action. However, the best methodologies are   not defined, leaving the success of these processes subject to   significant variation. A plethora of Root Cause Analysis (RCA)   methods are available, all based on the principles defined as   early as 1905 in the Lancet article "The Present State of Medical   Practice in the Rhondda   Valley"1, and expanded in "Definition   of a Root Cause" by Mark Paradies in October   20052. In the culmination of its   development from 1985 in the development of the   TapRoot®  RCA method. As stated in the   American Society for Quality (ASQ) book,   “Some   root cause analysis approaches are geared more toward identifying   true root causes than others; some are more general   problem-solving techniques, while others simply offer support for   the core activity of root cause   analysis.”3

  After years of experience with different   levels and definitions of investigation procedures and corrective   and preventive action (CAPA) activities, the Company recognized   the need for a more objective and precise identification of   systemic problems that were manifest in the continuing failure of   individual action plans. A formal Root Cause Analysis (RCA)   procedure and training were implemented to improve the   investigation phase, but the systemic root causes remained   elusive. Further research into behavioral safety led to the   seminal work “The   Human Factors


  Analysis and Classification System–HFACS”   by Scott   A. Shappell of the FAA Civil Aeromedical Institute, February   2000.4 The   HFACS was developed to address faults in highly-critical   industries such as aerospace and military readiness, and has been   adopted successfully by many other organizations. The company has   modified its Root Cause Analysis process to incorporate the HFACS   at the “contributory cause” level.  This change from the   more simplistic assignment of “operator errors” has removed the   assumption of blame to an improved understanding of the actions   that can be taken by the company to prevent errors.  The   significance of the formal linkage from operator actions to   corporate policies and structure cannot be overstated. A   description of the HFACS and how it has been applied to improving   asset Integrity and Reliability in the company will be   presented.



  1"The Present State of   Medical Practice in the Rhondda Valley".  The   Lancet166 (4290): 1507. 18 November   1905.


  2Mark Paradies, "Definition   of a Root Cause", 17 October 2005.


  3Bjørn Andersen and Tom   Fagerhaug Root Cause Analysis: Simplified Tools and   Techniques,   Pp. 5 & 13, ASQ Quality Press, March 24,   2006.


  4Shappell, S.A. and Wiegmann,   D.A., The Human Factors Analysis and   Classification System–HFACS,   FAA Civil Aeromedical Institute, Oklahoma City, OK; University of   Illinois at Urbana-Champaign, Institute of Aviation, Savoy, IL,   February 2000.



  Address (URL):