Safety in combat operations? An oxymoron, right? Safety professionals from the private sector and non-Department of Defense (DoD) agencies of the Federal Government might be surprised to discover that the Army, Navy, Air Force, Marines and Coast Guard each have a Safety Center with the mission to reduce or minimize accidental losses or mishaps. The US Army's Safety Center, recently re-designated the Combat Readiness Center (CRC), is continually integrating safety and Composite Risk Management into all phases of military operations, to include combat in Afghanistan and Iraq. With experience as an Army Safety Officer in Bosnia, Kosovo, and - most recently - Iraq, my purpose today is to present a brief introduction to the newly developed taxonomy for human factors analysis of accidents and apply it to our current challenges as we fight a war in Iraq.
Using the framework of the DoD Human Factors Analysis and Classification System, or DoD-HFACS, accident investigators can analyze the organizational and supervisory aspects of human error in a systematic manner. DoD-HFACS was adopted by the heads of the Safety Centers of all the military services in 2005 as the analytical model for human factors hazards in accident causation. (1) It builds upon the solid foundations of James Reason's "Swiss Cheese" model (2) and Douglas Weigmann and Scott Shappell's extensive work in aviation accident causation and prevention, to include the first HFACS model (3). Although my purpose today is not to describe the DoD-HFACS in detail, I will provide a brief overview of the system and the two models upon which it is based. Then, drawing upon personal experience from accident investigation and prevention during a one-year tour of duty in Iraq from August 2005 to August 2006, I will apply the DoD-HFACS causation model to a fatal accident that claimed the life of an Army Sergeant in Northern Iraq on November 17, 2005.
Reason's influential 1990 work, Managing the Risks of Organizational Accidents, amplified HW Heinrich's "Domino Theory" of accident causation, which proposed that mishaps are the end result of a sequence of errors made throughout a chain of command (4). Reason's model focused not only on the active failures of operators involved in the mishap, but on human error in the management and supervisory realms. His integration of latent failures or conditions into accident causation provided a more complete framework for investigators to identify and mitigate future accidents. In addition to the first of tier of analysis, Unsafe Acts of Operators, Reason added three more levels, each focused upon the organizational influences on errors. The second, third and fourth tiers, titled Preconditions for Unsafe Acts, Unsafe Supervision, and Organizational Influences, respectively, analyze the latent failures or conditions that may lie dormant or undetected until circumstances are right. Conditions such as fatigue, stress, or complacency may lead to the mishap, but they are not specific actions by an operator, they are preconditions that set the stage for the accident.