Overview
INTRODUCTION

In 2003, the Secretary of Defense (SECDEF) established a goal of reducing preventable accidents by 50%. SECDEF increased this goal to 75% in 2006. In support of this effort, the Air Force has been aggressively implementing safety programs and tools.

AFCMRS PROGRAM

The AFCMRS program is a web-based system which allows Air Force squadron, group, wing, NAF, and MAJCOM commanders to gain insight into their organization's safety culture by anonymously surveying members of their unit. Survey items target the categories of organizational processes, organizational climate, resources, and supervision. Results of the surveys allow commanders to target limited resources toward areas of concern and effect improvements in unit safety and mission effectiveness. The site provides functionality for survey respondents to provide their opinions by way of Likert scores and comments for each item and general open-ended statements. Unit commanders are provided a discreet code for their unit to view the survey feedback from those respondents and to compare their unit’s results to like units across USAF. The site is tailored to allow Air Force Safety Center personnel to administer AFCMRS surveys to hundreds of Air Force units every year. There are no dependencies between AFCMRS and other investments. Air Force Culture Assessment Safety Tool (AFCAST) is the predecessor to AFCMRS. All the data from AFCAST was incorporated into AFCMRS as AFCAST was improved and surveys added to AFCMRS.

HISTORICAL BACKGROUND

Human error has been shown to be the single largest contributing factor in industrial failures. Similar research indicates analogous conditions in the aviation, transportation, and high-technology industries. A great deal of attention has been paid to understanding human error in complex systems, including issues related to design, communication, and judgment. However, less attention has been paid to the impact of organizational influences on safety and performance. These surveys examine the organizational climate using a human factors framework.

An early model depicting organizational influences on loss control was introduced by Frank Bird (1974). His "Domino Theory" model posited that loss (i.e., a mishap) resulted from a sequence of events, each influencing the next (similar to that of falling dominos with each domino having a cause and effect on the next in the series). Figure 1 depicts the steps in Domino Theory.

Steps in Domino Theory

In the ensuing years, several other researches expanded upon Bird's work. Turner (1978) observed that organizational factors leading to a mishap could go unnoticed for long periods by system's designers or users. He defined this dormant period of unforeseen disaster as an "incubation period" which could persist for years before a "triggering event" generated a mishap. Turner indicated this triggering event could be confused as a "causal factor" of the mishap rather than the last event in the sequence of events leading to the mishap.

Perrow (1984) contended that as organizations and their technologies become more complex, they also become vulnerable to accidents [mishaps] stemming from unforeseen or misunderstood events. He termed this type accident a "normal accident" in the sense that it is an inherent part of complex systems that they will eventually fail. Perrow highlighted the essential role that organizations and management have in managing these systems.

James Reason (1990) built upon earlier error management research. He divided errors into two categories: (1) "active errors" that are almost immediately recognizable, and (2) "latent errors" that might lie dormant for a period of time until some precipitating event triggers the mishap (similar to Turner's incubation period). Reason introduced the "Swiss cheese" model of mishap causation. Figure 2 depicts the four tiers of Reason's model.

Reasons Swiss Cheese Model

Breakdown in interactions between these tiers results in "holes" in their respective defenses. It is these holes in the layered defenses that gives the name "Swiss cheese" to the model.

Wiegmann and Shappell (1996) fleshed out Reason's human error model by providing and defining subordinate categories to each of the model's four tiers. Their contribution resulted in the development of the Human Factors Analysis and Classification System (HFACS) - a model now recognized throughout DoD and becoming generally accepted in industry (refer to Figure 3).

DoD HFACS Model


Factor analyses of safety climate survey data have been conducted. These factor analyses point to survey item categorization that aligns well with the top two tiers of the DoD HFACS model ( Organizational and Supervisory factors). Thus, these two tiers are used to categorize Air Force survey data (refer to Figure 3).

AFCMRS Surveys

There are currently 15 AFCMRS surveys available on-line:
  • Operations Safety Culture Survey (OPS): Provides feedback to the squadron CC regarding aspects of the organizational safety climate as perceived by aircrew, missileers, and space ops personnel.
  • Maintenance Safety Culture Survey (MX): Provides feedback to the squadron CC regarding aspects of the organizational safety climate as perceived by maintenance personnel.
  • Support Personnel Safety Culture Survey (SUP): Provides feedback to the squadron CC regarding aspects of the organizational safety climate as perceived by general support personnel.
  • Higher Headquarters Survey (HHQ): Provides feedback to the squadron CC regarding perceptions of headquarters support and safety.
  • Air Force Voluntary Protection Program (VPP): Provides feedback to the squadron CC regarding VPP focused safety perceptions.
  • Driving Safety Survey (Driving Safety): Provides feedback to the squadron CC regarding perceptions of PMV use and organizational PMV climate.
  • Medical Safety Culture Survey (MED): Provides feedback to the squadron CC regarding aspects of the organizational safety climate as perceived by personnel in the non-nuclear, medical career field.
  • Nuclear Surety - Operations (NucMission-OPS): Provides feedback to the squadron CC regarding aspects of the nuclear surety safety climate as perceived by operations personnel.
  • Nuclear Surety - Maintenance (NucMission-MX): Provides feedback to the squadron CC regarding aspects of the nuclear surety safety climate as perceived by maintainer personnel.
  • Nuclear Surety - Support (NucMission-SUP): Provides feedback to the squadron CC regarding aspects of the nuclear surety safety climate as perceived by support personnel.
  • Nuclear Surety - non-PRP Support (NucMission-nonPRP): Provides feedback to the squadron CC regarding aspects of the nuclear surety safety climate as perceived by NON-PRP support personnel.
  • Nuclear Surety - Medical (NucMission-MED): Provides feedback to the squadron CC regarding aspects of the nuclear surety safety climate as perceived by medical support personnel.
  • Battlefield Airman Culture Survey (BA OPS): Provides feedback to the squadron CC regarding aspects of the organizational safety climate as perceived by personnel in the Battlefield Airman career fields e.g., CCT, STO, PJ, CRO, TACP, SOWT and SWO.
  • Space and Intelligence, Surveillance, and Reconnaissance Operations (SPC/ISR OPS): Provides feedback to the squadron CC regarding aspects of the organizational safety climate as perceived by personnel in the space and ISR operations career fields.
  • Space and Intelligence, Surveillance, and Reconnaissance Support (SPC/ISR SUP): Provides feedback to the squadron CC regarding aspects of the organizational safety climate as perceived by personnel providing direct support to space and ISR operations.



Notes:

(1) Duffey, R. and Saull, J. The probability and management of human error (Draft). Proceeding of 12th International Conference on Nuclear Engineering. April 25-29, 2004, Virginia.
(2) Bird, F. (1974). Management guide to loss control . Institute Press, Loganville, Georgia.
(3) Turner, B. (1978). Man-made disasters . Wykeham Publications, London, England.
(4) Perrow, C. (1984). Normal accidents: Living with high-risk technologies . Basic Books, New York.
(5) Reason, J. (1990). Human error . Cambridge University Press, New York.
(6) Wiegmann, D and Shappell S. (1996). A human error approach to aviation accident analysis: The human factors analysis and classification system . Ashgate, Great Britain.