Page 2 - HFACS Flipbook Holcim v 1.2
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INTRODUCTION
Most adverse events, including serious injuries, incidents and
near misses involve human error. Human errors are "occasions
in which planned sequence of mental or physical activity fails to
1
achieve its intended outcome."
Causes of errors are complex and often include human factor
issues such as system design and organizational processes
rather than individual incompetence.
The Human Factors Analysis and Classification System
(HFACS) an innovative and robust methodology for conducting
a comprehensive human factors analysis of adverse event.
This pocket guide is intended to provide a ready reference to
HFACS.
1 James Reason, 1990
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