İnsan Faktörleri Analiz ve Sınıflandırma Sistemi’nin (HFACS) Literatürde Yaygın Kullanımının Değerlendirilmesi

Yıl 2018, Cilt: 2 Sayı: 2, 156 - 176, 23.12.2018

Kadir Dönmez , Suat Uslu

https://doi.org/10.30518/jav.463607

Cited By: 8

Öz

İnsan Faktörleri
Analiz ve Sınıflandırma Sistemi (HFACS) 2000 yılında Shappell ve Wiegman
tarafından tanıtılmıştır. Temeli Reason’un İsviçre peyniri modeline dayanan
HFACS insan faktörlerini 4 seviye hata ile tanımlar; emniyetsiz davranışlar
(seviye-1), emniyetsiz davranışlara zemin hazırlayan koşullar (seviye-2),
emniyetsiz yönetim (seviye-3), örgütsel etkiler (seviye-4). İlk olarak Amerikan
deniz kuvvetleri için veri toplama ve analiz aracı olarak geliştirilmiştir. Günümüzde
ise HFACS’in sivil ve askeri alanda birçok uygulaması mevcuttur. İnsan
faktörleri veri toplama sürecinin kalitesini ve niceliğini artırırken veri
odaklı araştırma stratejilerinin verimini de artıran HFACS literatürde en
yaygın kullanılan kaza analiz aracıdır. Bu çalışmada HFACS içerisinde bulunan
insan hatası seviyelerinin detaylı anlatımı yapılmıştır. Bununla birlikte
HFACS’in havacılık literatüründe ve diğer sektörlerdeki yaygın kullanımı
araştırılmış ve HFACS’in havacılık uygulamaları, insan hatası ve emniyet yaklaşımları
açısından değerlendirilmiştir.

Anahtar Kelimeler

İnsan Faktörleri, , HFACS, Örgüt, Yönetim, Havacılık kazaları

Kaynakça

• [1] D. Wiegmann and S. Shappell, “Human Error Analysis of Commercial Aviation Accidents; Application of The Human Factor Analysis And Classification System”, Aviation, Space and Enviromental Medicine, 72 (11), 2001.
• [2] D. Wiegmann and S. Shappell, “Applying The Human Factors Analysis and Classification System (HFACS) to the Analysis of Commercial Aviatıon Accident Data”, 11th International Symposium on Aviation Psychology, Columbus, OH, 2001.
• [3] T. Griffin, M. Young and N. Stanton, “Human Factors Models For Aviation Accident Analysis and Prevention”, England: Ashgate Publishing Limited, 2015.
• [4] K. Dönmez, “Türk Hava Sahasında Meydana Gelen Ölümcül Uçak Kazalarına İnsan Faktörleri Analiz ve Sınıflandırma Sisteminin (HFACS) Uygulanması”, The Journal Of Academic Social Science Studies, 6 (59), 229-253, 2017.
• [5] J. Reason, “Human error: Models and management”, British Medical Journal, 172, 393–396, 2000.
• [6] J. Reason, “Managing the Risks of Organizational Accidents”, Farnham: Ashgate, 1997.
• [7] ATSB (Australian Transport Safety Bureau), “Human factors analysis of Australian aviation accidents and comparison with the United States”, Australia: Australian Transport Safety Bureau, 2007.
• [8] S. Shappell and D. Wiegmann, “A Human Error Analysis of General Aviation Controlled Flight Into Terrain Accidents Occurring Between 1990-1998”, Virginia: FAA - Federal Aviation Administration, 2003.
• [9] S. Shappell and D. Wiegmann, “The Human Factors Analysis and Classification System–HFACS”, Washington: U.S. Department of Transportation Federal Aviation Administration, 2000.
• [10] D. Wiegman, and S. Shappell, “A Human Error Analysis of Commercial Aviation Accidents Using the Human Factors Analysis and Classification System (HFACS)”, Oklahoma City: Federal Aviation Administration, 2001.
• [11] B. Villela, “Applying Human Factors Analysis and Classification System to Aviation Incidents in The Brazilian Navy”, Florida: Embry-Riddle Aeronautical University, 2011.
• [12] S. Shappell, C. Detwiler, K. Holcomb, C. Hackworth, A. Boquet, D. Wiegmann, “Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS”, Washington DC: Federal Aviation Administration, 2006.
• [13] S. Shappell, C. Detwiler, K. Holcomb, C. Hackworth, A. Boquet, D. Wiegmann, “Human Error and Commercial Aviation Accidents: An Analysis Using the Human Factors Analysis and Classification System”, Human Factors, 227-242, 2007.
• [14] W. Li, D. Harris and C. Yu, “Routes to failure: Analysis of 41 civil aviation accidents from the Republic of China using the human factors analysis and classification system”, Accident Analysis and Prevention, (40), 426–434, 2008.
• [15] L. Ting and D. Dai, “The Identification of Human Errors Leading to Accidents for improving Aviation Safety”, 14th International IEEE Conference on Intelligent Transportation Systems, Washington DC. pp.38, 2011.
• [16] D. Wiegmann, T. Faaborg, A. Boquet, C. Detwiler, K. Holcomb, S. Shappell, “Human Error and General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS”, Oklahoma City: Federal Aviation Administration, 2005.
• [17] M. Lenné, K. Ashby, and M. Fitzharris, “Analysis of General Aviation Crashes in Australia Using the Human Factors Analysis and Classification System”, The International Journal of Aviation Psychology, 340-352, 2008.[18] S. Shappell and D. Wiegmann, “HFACS Analysis of Military and Civilian Aviation Accidents: A North American Comparison”, Texas: International Society of Air Safety Investigators, 2004.
• [19] W. Li and D. Harris, “HFACS Analysis of ROC Air Force Aviation Accidents: Reliability Analysis and Cross-cultural Comparision”, International Journal of Applied Aviation Studies, 5 (1), 65-81, 2005.
• [20] W. Li and D. Harris, “Pilot error and its relationship with higher organizational levels: HFACS analysis of 523 accidents”, Aviation Space and Environzihinsel Medicine, 77 (10), 1056-1061, 2006.
• [21] W. Li and D. Harris, “Breaking the Chain: An Empirical Analysis of Accident Causal Factors by Human Factors Analysis and Classification System (HFACS)”, ISASI 2006 Annual Air Safety Seminar, Mexico, 2006.
• [22] N. Olsen and S. Shorrock, “Evaluation of the HFACS-ADF safety classification system: Inter-coder consensus and intra-coder consistency”, Accident Analysis and Prevention, (42), 437-444, 2009.
• [23] P. O Connor and P. Walker, “Evaluation of a human factors analysis and classification system as used by simulated mishap boards”. Aviation, Space and Environzihinsel Medicine, (81), 44-48, 2011.
• [24] T. Thaden, A. Gibbons, and T. Suzuki, “14 CFR Part 121 Air Carriers Maintenance Operations Casual Model: Human Error BBN Definitions and Integration”, Illinois: Fedaral Aviation Administration, 2007.
• [25] J. Rashid, “Human Factors Effects in Helicopter Maintenance: Proactive Monitoring and Controlling Techniques”, Cranfield: Cranfield University, 2010.
• [26] J. Rashid, C. Place and G. Braithwaite, “Helicopter maintenance error analysis: Beyond the third order of the HFACS-ME”, International Journal of Industrial Ergonomics, (40), 636-647, 2010.
• [27] S. Liu, C. Chi and W. Li, “The Application of Human Factors Analysis and Classification System (HFACS) to Investigate Human Errors in Helicopter Accidents”, Engineering Psychologyand and Cognitive Ergonomics, Taipei, 85-94, 2013.
• [28] S. Shappell and D. Wiegmann, “Air Traffıc Control (Atc) Related Accidents And Incidents: A Human Factors Analysis”, International Symposium on Aviation Psychology, Columbus, OH, 2001.
• [29] D. Broach and C. Dollar, “Relationship of Employee Attitudes and Supervisor-Controller Ratio to En Route Operational Error Rates”. Oklahoma City: Federal Aviation Administration, 2002.
• [30] A. Scarborough, L. Bailey and J. Pounds, “Examining ATC Operational Errors Using the Human Factors Analysis and Classification System”, Federal Aviation Administration, Oklahoma, 2005.
• [31] V. Yesilbas and T. Cotter, “Structural Analysis of HFACS in Unmanned And Manned Air Vehicles”, Proceedings of the American Society for Engineering Management 2014 International Annual Conference, 2014.
• [32] S. Reinach and A. Viale, “Application of a human error framework to conduct train accident/incident investigations”. Accident Analysis and Prevention, (38), 396–406, 2006.
• [33] Q. Zhan, W. Zheng, and B. Zhao, “A hybrid human and organizational analysis method for railway accidents based on HFACS-Railway Accidents (HFACS-RAs)”, Safety Science, (91), 232-250, 2017.
• [34] M. Baysari, C. Caponecchia, A. McIntosh, J. Wilson, “Classification of errors contributing to rail incidents and accidents: A comparison of two human error identification techniques”, Safety Science, (47), 948-957, 2009.
• [35] M. Baysari, A. McIntosh and J. Wilson, “Understanding the human factors contribution to railway accidents and incidents in Australia”, Accident Analysis and Prevention, (40), 1750-1757, 2008.
• [36] J. Hinrichs, M. Baldauf, and K. Ghirxi, “Accident investigation reporting deficiencies related to organizational factors in machinery space fires and explosions” Accident Analysis and Prevention, (43), 1187-1196, 2011.
• [37] E. Akyüz and M. Çelik, “Utilisation of cognitive map in modelling human error in marine accident analysis and prevention”, Safety Science, (70),19-28. 2014.
• [38] M. Celik, and S. Çebi, “Analytical HFACS for investigating human errors in shipping accidents”, Accident Analysis and Prevention, (41), 66-75. 2009.
• [39] J. Bilbro, “An Inter-Rater Comparison Of Dod Human Factors Analysis And Classification System (HFACS) And Human Factors Analysıs And Classıfıcatıon System-Marıtıme (HFACS-M)”, California: Naval Postgraduate School, 2013.
• [40] D. Harris and W. Li, “An extension of the Human Factors Analysis and Classification System for use in open systems”, Theoretical Issues in Ergonomics Science, 108-128, 2011.
• [41] R. Cintron, “Human Factors Analysis and Classification System Interrater Reliability for Biopharmaceutical Manufacturing Investigations”, Washington: Walden University, 2015.
• [42] T. Diller, G. Helmrich, S. Dunning, S. Cox, A. Buchanan and S. Shappell, “The Human Factors Analysis Classification System (HFACS) Applied to Health Care”, American Journal of Medical Quality, 29(3), 181-190, 2014.
• [43] A. Ergai, “Assessment of the Human Factors Analysis and Classification System (HFACS): Intra-rater and Inter-rater Reliability”, South Carolina: TigerPrints, 2013.
• [44] J. Patterson and S. Shappell, “Operator error and system deficiencies: Analysis of 508 mining incidents and accidents from Queensland, Australia using HFACS”, Accident Analysis and Prevention, (42), 1379–1385, 2010.
• [45] SHGM (Sivil Havacılık Genel Müdürlüğü), “Emniyet Yönetim Sistemi Temel Esaslar”, Ankara: Sivil Havacılık Genel Müdürlüğü Yayınları, 2012.
• [46] Airbus, “A Statistical Analysis of Commercial Aviation Accidents 1958-2016”. France: Airbus S.A.S, (2017).
• [47] K. Dönmez, “21. Yüzyıl Havacılık Olaylarında Operasyon Organizasyon İlişkisi: İnsan Faktörleri Analiz ve Sınıflandırma Sistemi Uygulaması”, Anadolu Üniversitesi Fen Bilimleri Ensititüsü. Eskişehir, 2018.