Attachment_3_(Part_2)_-_HFACS_Code_Incident_Frequency_Matrix.xlsx

XLSX spreadsheet 28 KB Posted Oct 9, 2015

Attached to: Safety Review Services Federal contract opportunity
Solicitation number: N32205-16-R-2004
Issued by: Department of the Navy Military Sealift Command

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Attachment 3 (Part 2) - HFACS Code Incident Frequency Matrix

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File	Type	Posted
N32205-16-R-200405.pdf	PDF	Dec 21, 2015
Amendment_04.docx	DOCX document	Dec 8, 2015
Amendment_03.docx	DOCX document	Nov 30, 2015
Amendment_01.docx	DOCX document	Nov 12, 2015
Amendment_02.docx	DOCX document	Nov 12, 2015
Attachment_7_-_Past_Perf_Questionnaire.doc	DOC document	Oct 9, 2015
Attachment_11-_Pricing_Spreadsheet.xlsx	XLSX spreadsheet	Oct 9, 2015
Attachment_8_-_SFLLL.pdf	PDF	Oct 9, 2015
Attachment_1_(Part_1)_-_Safety_Management_Procedures.docx	DOCX document	Oct 9, 2015
Attachment_3_(Part_1)_-_Incident_List.docx	DOCX document	Oct 9, 2015
Attachment_10_-_PAP.doc	DOC document	Oct 9, 2015
Attachment_2_-_GOCO_Operators_and_Classes.docx	DOCX document	Oct 9, 2015
Attachment_5_-_DD254.pdf	PDF	Oct 9, 2015
Attachment_4_-_Inspection_and_Audit_Report.docx	DOCX document	Oct 9, 2015
Attachment_6_-_Past_Perf_Data_Sheet.doc	DOC document	Oct 9, 2015
Attachment_1_(Part_2)_-_Report_Structure.docx	DOCX document	Oct 9, 2015
Attachment_9_-_NDAs.docx	DOCX document	Oct 9, 2015
RFP_N32205-16-R-2004.docx	DOCX document	Oct 9, 2015

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Findings

HFACS

GIANELLA Allision

MARTIN Allision

MOBRO Collision

FISHER F/O Spill

WATERS Laundry Fire

SACAGAWEA Allision

KOCAK Grounding

KOCAK B. Explosion

ALPINE ETERNITY Allision

FISHER Break fm Mooring & Grounding

FISHER Break from Mooring

Incident Date

24 Apr '13

26 Sep '13

20 Dec '13

9 Jul '14

16 Sep '14

5 Nov '14

22 Jan '15

8 Mar '15

22 Mar '15

14 Apr '15

16 Jun '15

Incident Briefing Team

Sara/Eric

Kevin/Mike

Sara/Eric

Rob/Mimi

Frank/Rich

Fred/Linda

Rob/Mimi

Fred/Linda

Kevin/Mike

Sara/Eric

Code

Descriptor (Definitions on Sheet

ACTS (Active Failures or Actions)

Performance-Based Errors (AE100)

AE102

Checklist Not Followed Correctly

1/2

AE103

Procedure Not Followed Correctly

9/18

AE104

Uncontrolled Vehicle

1/2

AE105

Breakdown in Visual Scan

4/5

AE107

Rushed or Delayed a Necessary Action

5/8

Judgment & Decision-Making Errors (AE200)

AE201

Inadequate Real-Time Risk Assessment

10/20

AE202

Failure to Prioritize Tasks Adequately

5/5

AE205

Ignored a Caution/Warning

7/9

AE206

Wrong Choice of Action During an Operation

8/13

Violations (AV000)

AV001

Performs Work-Around Violation

2/3

AV002

Commits Widespread/Routine Violation

0/0

AV003

Extreme Violation-Lack of Discipline

2/2

Preconditions (Latent Failures or Conditions)

Physical Environment (PE100)

PE101

Environmental Conditions Affecting Vision

1/1

PE103

Vibration Affects Vision or Balance

0/0

PE106

Heat/Cold Stress Impairs Performance

0/0

PE108

External Force or Object Impeded an Individual's Movement

0/0

PE109

Lights of Other Vehicle/Vessel/Aircraft Affected Vision

0/0

PE110

Noise Interference

0/0

Technological Environment (PE200)

PE201

Seat and Restraint System Problems

0/0

PE202

Instrumentation and Warning System Issues

1/1

PE203

Visibility Restrictions (Not Weather Related)

0/0

PE204

Controls and Switches are Inadequate

1/2

PE205

Automated System Creates an Unsafe Situation

2/5

PE206

Workspace Incompatible with Operation

0/0

PE207

Personal Equipment Interference

0/0

PE208

Communication Equipment Inadequate

0/0

Physical Problem (PC300)

PC302

Substance Effects (Alcohol, Supplements, Medications, Drugs)

0/0

PC304

Loss of Consciousness (Sudden or Prolonged Onset)

0/0

PC305

Physical Illness/Injury

0/0

PC307

Fatigue

1/1

PC310

Trapped Gas Disorders

0/0

PC311

Evolved Gas Disorders

0/0

PC312

Hypoxia/Hyperventilation

0/0

PC314

Inadequate Adaptation to Darkness

0/0

PC315

Dehydration

0/0

PC317

Body Size/Movement Limitations

0/0

PC318

Physical Strength and Coordination (Inappropriate for Task Demands)

0/0

PC319

Nutrition/Diet

0/0

State of Mind (PC200)

PC202

Psychological Problem

0/0

PC203

Life Stressors

0/0

PC204

Emotional State

0/0

PC205

Personality Style

0/0

PC206

Overconfidence

8/16

PC207

Pressing

0/0

PC208

Complacency

7/14

PC209

Motivation

2/2

PC215

Motivational Exhaustion (Burnout)

0/0

Sensory Misperception (PC500)

PC501

Motion Illusion - Kinesthetic

0/0

PC502

Turning/Balance Illusion-Vestibular

0/0

PC503

Visual Illusion

0/0

PC504

Misperception of Changing Environment

4/6

PC505

Misinterpreted/Misread Instrument

1/1

PC507

Misinterpretation of Auditory/Sound Cues

0/0

PC508

Spatial Disorientation

0/0

PC511

Temporal/Time Distortion

0/0

Mental Awareness (PC100)

PC101

Not Paying Attention

5/8

PC102

Fixation

3/3

PC103

Task Oversaturation/Undersaturation

1/1

PC104

Confusion

1/1

PC105

Negative Habit Transfer

2/2

PC106

Distraction

1/3

PC107

Geographically Lost

0/0

PC108

Interference/Interruption

0/0

PC109

Technical or Procedural Knowledge Not Retained After Training

0/0

PC110

Inaccurate Expectation

3/4

Teamwork (PP100)

PP101

Failure of Crew/Team Leadership

6/7

PP103

Inadequate Task Delegation

2/5

PP104

Rank/Position Intimidation

0/0

PP105

Lack of Assertiveness

3/5

PP106

Critical Information Not Communicated

6/10

PP107

Standard/Proper Terminology Not Used

0/0

PP108

Failed to Effectively Communicate

8/10

PP109

Task/Mission Planning/Briefing Inadequate

5/6

Supervision

Supervisory Violations (SV000)

SV001

Failure to Enforce Existing Rules (Supervisory Act of Omission)

4/4

SV002

Allowing Unwritten Policies to Become Standard

1/1

SV003

Directed Individual to Violate Existing Regulations

0/0

SV004

Authorized Unqualified Individuals for Task

0/0

Planned Inappropriate Operations

SP001

Directed Task Beyond Personnel Capabilities

0/0

SP002

Inappropriate Team Composition

2/3

SP003

Selected Individual with Lack of Current or Limited Experience

2/2

SP006

Performed Inadequate Risk Assessment and/or Mitigation

7/10

SP007

Authorized Unnecessary Hazard

1/1

Inadequate Supervision (SI000)

SI001

Supervisory/Command Oversight Inadequate

7/16

SI002

Improper Role-Modeling

1/1

SI003

Failed to Provide Proper Training

1/1

SI004

Failed to Provide Appropriate Policy/Guidance

7/21

SI005

Personality Conflict with Supervisor

0/0

SI006

Lack of Supervisory Responses to Critical Information

3/6

SI007

Failed to Identify/Correct Risky or Unsafe Practices

2/2

SI008

Selected Individual with Lack of Proficiency

3/3

Organizational Influences

Resource Problems (OR000)

OR001

Command and Control Resources Are Deficient

3/4

OR003

Inadequate Infrastructure

1/1

OR005

Failure to Remove Inadequate / Worn-out Eqpt in a Timely Manner

1/1

OR008

Failure to Provide Adequate Operational Information Resources

3/7

OR009

Failure to Provide Adequate Funding

4/6

Personnel Selection & Staffing (OS000)

OS001

Personnel Recruiting and Selection Policies Are Inadequate

1/1

OS002

Failure to Provide Adequate Manning/Staffing Resources

3/5

Policy and Process Issues (OP000)

OP001

Pace of Ops Tempo/Workload

2/2

OP002

Organizational Program / Policy Risks Not Adequately Assessed

3/5

OP003

Provided Inadequate Procedural Guidance or Publications

6/6

OP004

Organizational (Formal) Training is Inadequate or Unavailable

0/0

OP005

Flawed Doctrine/Philosophy

5/10

OP006

Inadequate Program Management

1/1

OP007

Purchasing or Providing Poorly Designed or Unsuitable Equipment

2/3

Climate/Culture Influences (OC000)

OC001

Organizational Culture (Attitude/Actions) Allows for Unsafe Task/Mission

5/7

OC003

Organizational Overconfidence or Underconfidence in Equipment

5/7

OC005

Organizational Structure is Unclear or Inadequate

2/3

Definitions

HFACS
Incident Date
Incident Briefing Team
Code	Descriptor (Definitions on Sheet
ACTS (Active Failures or Actions)		What did the person do, or not do, to cause the mishap? (Was this a case of pushing the wrong button, made a bad decision, and/or violated a rule or regulation).
Performance-Based Errors (AE100)
AE102	Checklist Not Followed Correctly
AE103	Procedure Not Followed Correctly
AE104	Uncontrolled Vehicle
AE105	Breakdown in Visual Scan
AE107	Rushed or Delayed a Necessary Action
Judgment & Decision-Making Errors (AE200)
AE201	Inadequate Real-Time Risk Assessment
AE202	Failure to Prioritize Tasks Adequately
AE205	Ignored a Caution/Warning
AE206	Wrong Choice of Action During an Operation
Violations (AV000)
AV001	Performs Work-Around Violation
AV002	Commits Widespread/Routine Violation
AV003	Extreme Violation-Lack of Discipline
Preconditions (Latent Failures or Conditions)		Why did the person do this unsafe act? Was the Mishap Person fatigued? Was the Mishap Person going through a divorce? Complacent? Trying to accomplish the evolution in less than ideal conditions?
Physical Environment (PE100)
PE101	Environmental Conditions Affecting Vision
PE103	Vibration Affects Vision or Balance
PE106	Heat/Cold Stress Impairs Performance
PE108	External Force or Object Impeded an Individual's Movement
PE109	Lights of Other Vehicle/Vessel/Aircraft Affected Vision
PE110	Noise Interference
Technological Environment (PE200)
PE201	Seat and Restraint System Problems
PE202	Instrumentation and Warning System Issues
PE203	Visibility Restrictions (Not Weather Related)
PE204	Controls and Switches are Inadequate
PE205	Automated System Creates an Unsafe Situation
PE206	Workspace Incompatible with Operation
PE207	Personal Equipment Interference
PE208	Communication Equipment Inadequate
Physical Problem (PC300)
PC302	Substance Effects (Alcohol, Supplements, Medications, Drugs)
PC304	Loss of Consciousness (Sudden or Prolonged Onset)
PC305	Physical Illness/Injury
PC307	Fatigue
PC310	Trapped Gas Disorders
PC311	Evolved Gas Disorders
PC312	Hypoxia/Hyperventilation
PC314	Inadequate Adaptation to Darkness
PC315	Dehydration
PC317	Body Size/Movement Limitations
PC318	Physical Strength and Coordination (Inappropriate for Task Demands)
PC319	Nutrition/Diet
State of Mind (PC200)
PC202	Psychological Problem
PC203	Life Stressors
PC204	Emotional State
PC205	Personality Style
PC206	Overconfidence
PC207	Pressing
PC208	Complacency
PC209	Motivation
PC215	Motivational Exhaustion (Burnout)
Sensory Misperception (PC500)
PC501	Motion Illusion - Kinesthetic
PC502	Turning/Balance Illusion-Vestibular
PC503	Visual Illusion
PC504	Misperception of Changing Environment
PC505	Misinterpreted/Misread Instrument
PC507	Misinterpretation of Auditory/Sound Cues
PC508	Spatial Disorientation
PC511	Temporal/Time Distortion
Mental Awareness (PC100)
PC101	Not Paying Attention
PC102	Fixation
PC103	Task Oversaturation/Undersaturation
PC104	Confusion
PC105	Negative Habit Transfer
PC106	Distraction
PC107	Geographically Lost
PC108	Interference/Interruption
PC109	Technical or Procedural Knowledge Not Retained After Training
PC110	Inaccurate Expectation
Teamwork (PP100)
PP101	Failure of Crew/Team Leadership
PP103	Inadequate Task Delegation
PP104	Rank/Position Intimidation
PP105	Lack of Assertiveness
PP106	Critical Information Not Communicated
PP107	Standard/Proper Terminology Not Used
PP108	Failed to Effectively Communicate
PP109	Task/Mission Planning/Briefing Inadequate
Supervision		What was Supervisions Role in this Mishap? Many times, it's a case where someone in the Supervisory chain knew about the Mishap Person's preconditions but didn't take steps to prevent the mishap. Perhaps there were SOP's in place but they were unclear or unenforced.
Supervisory Violations (SV000)
SV001	Failure to Enforce Existing Rules (Supervisory Act of Omission)
SV002	Allowing Unwritten Policies to Become Standard
SV003	Directed Individual to Violate Existing Regulations
SV004	Authorized Unqualified Individuals for Task
Planned Inappropriate Operations
SP001	Directed Task Beyond Personnel Capabilities
SP002	Inappropriate Team Composition
SP003	Selected Individual with Lack of Current or Limited Experience
SP006	Performed Inadequate Risk Assessment and/or Mitigation
SP007	Authorized Unnecessary Hazard
Inadequate Supervision (SI000)
SI001	Supervisory/Command Oversight Inadequate
SI002	Improper Role-Modeling
SI003	Failed to Provide Proper Training
SI004	Failed to Provide Appropriate Policy/Guidance
SI005	Personality Conflict with Supervisor
SI006	Lack of Supervisory Responses to Critical Information
SI007	Failed to Identify/Correct Risky or Unsafe Practices
SI008	Selected Individual with Lack of Proficiency
Organizational Influences
Resource Problems (OR000)		What was the organization's role in the Mishap? Perhaps the Mishap person was given procedures to use that were unclear or the training they received was inadequate. It could also be because of budget issues or the improper selection of personnel.
OR001	Command and Control Resources Are Deficient
OR003	Inadequate Infrastructure
OR005	Failure to Remove Inadequate / Worn-out Eqpt in a Timely Manner
OR008	Failure to Provide Adequate Operational Information Resources
OR009	Failure to Provide Adequate Funding
Personnel Selection & Staffing (OS000)
OS001	Personnel Recruiting and Selection Policies Are Inadequate
OS002	Failure to Provide Adequate Manning/Staffing Resources
Policy and Process Issues (OP000)
OP001	Pace of Ops Tempo/Workload
OP002	Organizational Program / Policy Risks Not Adequately Assessed
OP003	Provided Inadequate Procedural Guidance or Publications
OP004	Organizational (Formal) Training is Inadequate or Unavailable
OP005	Flawed Doctrine/Philosophy
OP006	Inadequate Program Management
OP007	Purchasing or Providing Poorly Designed or Unsuitable Equipment
Climate/Culture Influences (OC000)
OC001	Organizational Culture (Attitude/Actions) Allows for Unsafe Task/Mission
OC003	Organizational Overconfidence or Underconfidence in Equipment
OC005	Organizational Structure is Unclear or Inadequate

Sheet2 HFACS Definitions

Sheet3

File details come from the government source that posted it. Updated Nov 14, 2017.