When a mishap or close call occurs, there’s always a human component to consider. It’s not about blame, but rather understanding the circumstances around the incident and how they can be avoided in the future to prevent recurrence.

The two courses “Human Factors in Mishap Investigation” (SMA-SAFE-OSMA-4004) and (SMA-002-15) present NASA’s traditional mishap approach to Human Factors through the use of Performance Shaping Factors as an investigation tool. Recently, NASA started to delve into the Human Factors Analysis and Classification System, commonly known as HFACS. This more comprehensive approach looks into each individual connected to an incident rather than just the collective, allowing investigators to pinpoint specific human errors. For example, investigators could find that despite being trained, an employee may not have understood the process or how to do his job, as opposed to a more general finding of insufficient training. 

“NASA has taken the next step in enhancing its Mishap Investigation process by looking at the Human Factors inputs in mishaps and how we can look at Human Factors to further the mission for deep space exploration,” said Gerry Schumann, Institutional Safety program executive.

The course provides participants with basic concepts and the information necessary to perform Human Factors analyses in mishap and close call investigations. It covers the factors that affect human performance, how those factors can cause or contribute to the occurrence of incidents, and how to apply the acquired Human Factors knowledge and skills to relevant investigation activities. Topics include

• Internal and external performance-shaping factors and how those relate to human events
• Human error
• Human conditions
• The different types of human events, errors and conditions
• Identification, evaluation and selection of appropriate barriers, controls and amelioration methods

All of NASA’s mishap program managers went through HFACS training at Johnson Space Center, taught directly by the developers of this method.  

To date, HFACS has been used as a part of two NASA mishap investigations. As a result, the investigators were able to look in-depth at different areas, including employee routines, wide-spread issues where routine violations occurred, a lack of discipline and errors in decision-making.

“It really helped us see what some of these Human Factor elements were and how we can make them better,” said Schumann. “It did help out a lot being able to talk about the climate and get the folks more engaged and identify unsafe demands. It opened a lot of people’s eyes.”

Schumann recommends that any past board members take the newer training to see how it supplements the processes they’ve already learned. He also believes anyone identified as a center Human Factors expert — and each center has one — should take the training to get an understanding of what NASA expects within the context of a mishap investigation.