HFACS Definitions

Below are a list of definitions for our HFACS framework 


  • Organizational Culture – The shared values, beliefs, and priorities regarding safety that govern organizational decision-making, as well as the willingness of an organization to openly communicate and learn from adverse events.
  • Operational Process How an organization plans to accomplish its mission, as reflected by its strategic planning, policies/procedures, and corporate oversight.
  • Resource Management – Support provided by senior leadership to accomplish the objectives of the organization, including the allocation of human, equipment/facility, and monetary resources.


  • Inadequate Supervision – Oversight and management of personnel and resources, including training, professional guidance, and operation leadership.
  • Planned Inappropriate Operations – Management and assignment of work including aspects of risk management, staff assignment, work tempo, scheduling, etc.
  • Failure to Correct Known Problem – Those instances when deficiencies among individuals or teams, problems with equipment, or hazards within the environment, are known to the supervisor but are allowed to continue unabated.
  • Supervisory Violation – The willful disregard for existing rules, regulations, instructions, or standard operating procedures by management during the course of their duties.


Situational Factors

  • Tools/Technology – This category encompasses a variety of issues including the design of equipment and controls, displays/interface characteristics, checklist layout, and automation.
  • Task – Refers to the nature of the activities performed by individuals and teams including such things as the complexity, criticality, and consistency of assigned work.
  • Physical Environment – This category includes the setting in which the individual performs their work and consists of such things as lighting, layout, noise, clutter, and workplace design.

Team Factors

  • Leadership – The team leader’s performance of his/her responsibilities such as the failure to adopt a leadership role or model/reinforce principles of teamwork.
  • Communication – The sharing of information among team members including providing/requesting information and the failure to provide two-way (positive confirmation) communication.
  • Coordination – This category describes the interrelationship among team members including such things as planning, monitoring, and providing back-up where necessary.

Individual Factors

  • Mental State – Psychological/mental conditions that negatively affect performance such as mental fatigue, pernicious attitudes, misplaced motivation, and cognitive states such as distraction, mental workload, and confusion.
  • Physiological State – Medical/physiological conditions that preclude safe operations such as illness, intoxication, and the myriad of pharmacological and medical abnormalities known to affect performance.
  • Fitness for Duty – Off-duty activities that negatively impact performance on the job such the failure to adhere to sleep/rest requirements, alcohol restrictions, and other off-duty mandates.



  • Decision Errors – These “thinking” errors represent conscious, goal-intended behavior that proceeds as intended, yet the plan proves inadequate or inappropriate for the situation. These errors typically result from a lack of information, knowledge or experience.
  • Skill-based Errors – Highly practiced behavior that occurs with little or no conscious thought. These “doing” errors frequently appear as attention failures, memory failures, or errors associated with the technique with which one performs a task.
  • Perceptual Errors – These errors involve the five senses: seeing, hearing, touching, tasting, and smelling. It is not unusual for these senses to become inaccurate or confused in sensory impoverished environments or degraded simply due to normal aging.


  • Routine Violations – Often referred to as “bending the rules,” this type of violation tends to be habitual by nature, engaged in by others, and is often enabled by a system of supervision and management that tolerates such departures from the rules.
  • Exceptional Violations – Isolated departures from the rules, neither typical of the individual nor condoned by management