HFIX designed to help develop innovative ideas or solutions for addressing problems identified during your HFACS root cause analysis (RCA), or any problem that may come up in life. While such solutions may be called by many different names, such as “interventions,” “corrective actions,” or “risk mitigation strategies,” the challenge is the same. Generating novel or creative solutions is a difficult task.
Sometimes people have difficulty discovering new ways of solving a problem or they may feel uncomfortable thinking “outside their box.” As a result, they may limit their approach, focusing on only a very narrow set of options. Other times, people tend to look for “the best way” to attack an issue, hoping to find the one “silver bullet” that will completely eliminate the problem. However, such panaceas rarely exist and in the search for such a solution other opportunities for intervening are often ignored or overlooked.
The best approach for generating innovative ideas to solve a problem is to first come up with as many potential solutions as possible. However, a large number of solutions is not enough. Solutions should also address the problem from a variety of different approaches or perspectives. In other words, interventions need to attack the same problem from many different angles.
The Human Factors Intervention Matrix (HFIX) is designed to help you accomplish these goals. Specifically, HFIX consists of a series of probes or questions that help you uncover multiple interventions to address a problem. As result, HFIX facilitates the generation of a greater variety of approaches to attacking the same problem. The result is a more comprehensive list of possible solutions to choose from.
HFIX approaches:
- Environment Approach: Generate ideas for the user on how modifying the physical environment can solve their problem. For instance, consider changes in lighting, workspace arrangements, or noise levels. Try to think about solving the problem by exploring such questions as (this is not an exhaustive list):
- How could the number of distractions in the environment be reduced to allow the operator to focus attention more fully on the task?
- How could workspace arrangements or dimensions be modified to improve task performance?
- How could the workspace be made suitable for the range of individuals who will use the facility?
- How could lighting be changed to reduce shadows, glare, or stark lighting changes (e.g., going from light to dark settings)?
- How could the noise level be modified or reduced to reduce fatigue, improve concentration or enhance communication?
- How could the temperature conditions be modified or improved to improve concentration, mood, or performance? How could physical/technological barriers to performance or communication be modified or rearranged?
- How could the physical arrangement of workspaces/rooms be standardized to reduce confusion, delays or errors?
- How could floor surfaces be modified or improved to allow for better movement or rearrangement of equipment when needed?
- How could clutter be reduced or housekeeping improved to make the working environment more conducive to safe and productive work?
- Task/Workload Approach: Generate ideas for the user on ways to restructure tasks or workflow to solve the problem. Think about checklists, feedback mechanisms, and task clarity. Try to think about solving the problem by exploring such questions as (this is not an exhaustive list):
- How can the task be restructured so that it requires less reliance on human memory (i.e., use checklists or technology that signals next step in task)?
- If the task is done simultaneously with other tasks (divided attention), can it be done by itself? How can the mental workload/timesharing be reduced?
- How could errors in performing the task be reduced by having another team member check/verify important steps in the procedure?
- How could checklists be developed to guide the task or verify that the task has been performed properly?
- How could immediate feedback be integrated into the task to allow operators to know when they have done things correctly or incorrectly?
- How can procedures or checklist be redesigned to be clearer or more user-friendly?
- If the task allows for easy short-cuts, how could it be redesigned to eliminate these shortcuts or reduce the likelihood that they are done?
- How could procedures be re-written so that they are less ambiguous or inapplicable to the safety critical tasks operators perform?
- How could procedures be developed that restrict the performance of safety critical tasks when there is time pressure to complete it?
- When operators switch tasks, what procedures could be developed to reduce negative transfer (habit interference)? If compliance with safe work practices goes unrewarded, how can a reward system be developed to ensure that compliance is reinforced?
- If a task is repetitive, monotonous, or boring, how could it be made more interesting? How could “time on task” be changed to reduce vigilance decrements or mental lapses in attention?
- Could operators be rotated off the tasks, checked for errors, or monitored more closely?
- Could the pacing or ordering of a particular task be modified to reduce opportunities for error?
- How could a task be modified to reduce the demands on the operator’s physical or perceptual limitations?
- How could the task be redesigned so that its requirements are within reasonable bounds/limits of all persons performing the job (e.g., force, speed, precision, requirements, etc.)?
- Are the various tasks performed appropriately grouped into jobs? How could similar tasks be more effectively grouped/assigned to operators so that they are performed by operators with the same skills?
- Tools/Technology Approach: Generate ideas for the user on how tools and technology can be leveraged to improve performance. This might involve digital tools, communication devices, or automation. Try to think about solving the problem by exploring such questions as (this is not an exhaustive list):
- How can warnings or alarms be improved to increase operators’ awareness of hazards or the presence of abnormal conditions?
- How can tools or technologies be redesigned to enter into “failsafe” mode when problems occur?
- How could safeguards or personnel protective equipment be improved to reduce the consequences of errors?
- How could tools, checklists, manuals or displays be redesigned to reduce confusion and errors? (e.g., bold face items in checklist that are most important and/or should be memorized).
- How could automation help in reducing the dependency on human performance of certain tasks?
- Are better tools currently on the market but not purchased by the company? What are these tools and how would they reduce errors on the job?
- How could technologies be developed to reduce the task demands on the human decision-making processes, perceptual processes, or physical limitations?
- How could operator tools be more effectively designed to improve operator performance and/or reduce injuries?
- How could controls be more easily identified and/or better designed in terms of shape, size and other relevant considerations?
- How could information sources be integrated or located in a more effective manner?
- How can system redundancy be improved for critical functions? For example, better backup or parallel components (persons or machines).
- How could the design/operation of tools, workplaces, vehicles, etc. be standardized to prevent negative transfer or confusion?
- How could tools/technology be developed to reduce the physical demand on the operator?
- How could equipment be redesigned for convenient maintenance?
- How could inspection or troubleshooting aids be developed to ensure equipment is in proper working condition?
- How could maintenance procedures or schedules be improved to prevent equipment from failing during use?
- Individual/Team Approach: Generate ideas for the user on how changes could be made to the individuals and teams involved in activity. Think about incentives, training, team briefings, and stress management. Try to think about solving the problem by exploring such questions as (this is not an exhaustive list):
- How could changes be made to the way in which individuals are recruited or selected for employment to ensure that they have the appropriate knowledge and skills necessary to perform their required tasks safely and efficiently?
- How could individual’s motivation to perform their tasks safely be improved or incentivized?
- How could the content of training programs be developed or modified to improve individual’s knowledge of procedures or tasks?
- How can the method of training delivery be improved or modified to enhance its impact on individual’s knowledge and skills (e.g., use of simulation)?
- How could individual’s retention and compliance with new policies and procedures be better monitored and evaluated (e.g., recurrent testing or drills)?
- How could individual’s stress and fatigue be reduced or monitored to improve safety and performance?
- How could individual’s readiness or “fitness for duty” be improved or monitored at the beginning and throughout their shift?
- How could individual’s decision-making or situational awareness be improved to reduce errors (e.g., decision aids or better information)?
- How could verbal communication procedures be improved to reduce the likelihood of miscommunication among team members (e.g., standardization of phraseology or readback/callback procedures)?
- How could the use of non-verbal communication (e.g., gestures or hand signals) be developed and standardized to improve communication?
- How could team briefings/planning sessions be developed or improved to improve communication and coordination?
- How could debriefings be used or developed to help team members share experiences and learn from their past activities together?
- How could crew pairing procedures be improved to ensure crew compatibility, in terms of experience, personality, language, or other critical factors?
- How could procedures be developed to improve the interactions among team members, such as empowering inexperienced operators to challenge experienced operators on safety critical issues?
- When individuals are working as a team, how could the responsibilities of each team member be more clearly defined?
- How could changes be made to ensure that team leaders are identifiable and responsible?
- How could handoffs/handovers be developed or improved to benefit the communication and transition among team members?
- How could team membership be standardized to ensure adequate familiarity and communication among team members?
- How could the integration of new team members into the group be enhanced to ensure good communication and coordination?
- How can the timing of communication be modified so it does not distract or overburden individuals involved (e.g., “sterile cockpit” rule)?
- Supervisor/Organizational Approach: Generate ideas for the user on how changes at the supervisory and organizational levels could be made to promote effective performance or help solve the problem. Consider culture changes, training, leadership engagement, and policy enhancements. Try to think about solving the problem by exploring such questions as (this is not an exhaustive list):
- How could the selection and/or promotion of supervisors be improved to enhance the quality of front line supervision?
- How could methods be developed to improve supervisors’ communication with their staff?
- How could incentives be implemented to encourage supervisors to be more actively concerned or involved in safety issues in their unit?
- How could changes be made to better empower supervisors to correct problems or address concerns?
- How could training or experience of supervisors be modified to improve supervisory oversight and planning?
- How could supervisory involvement and oversight/monitoring be improved to impact safety?
- How could production pressures on supervisors be changed to reduce the impact on unsafe acts?
- How could the awareness and appreciation of hazards and risk by supervisors be enhanced?
- How could standard operating procedures (SOP’s) be modified to reduce risks and improve safety?
- How could the organization and/or supervisor ensure that SOPs are in place and that they are relevant and not out-of-date?
- How could operational risk management procedures be implemented to reduce safety hazards?
- How could tools for helping supervisors plan activities and set goals be improved?
- What tools or job aids could be developed to help supervisors create schedules, improve team composition or reduce operator fatigue?
- How could the organization change its processes for holding supervisors accountable for enforcing the rules?
- How could the organization improve its process for recruiting and hiring people who are better qualified or more experienced?
- How could the organization improve its process for evaluating and purchasing equipment that is user friendly and designed for safety?
- How could leadership better communicate the importance and value of safety?
- How could the organization better disseminate and share safety information or lessons learned from safety events across units (i.e., become more transparent)?
- How could the organization better promote, reinforce or encourage safe practices?
- How could the organization’s structure be redesigned to improve the coordination and integration of activities across divisions/departments?
- How could policies (e.g.,promotion, sick leave, overtime, etc.) within the organization be changed to improve safety?
- How could leadership become more engaged with staff or more aware of safety issues (e.g., leadership “walk-arounds”)?
- How could the organization improve its contingency planning for possible staff shortages, equipment failures, or budgetary restrictions?
- What tools could be developed to help supervisors identify problems with workplace design or layout?
- How could the organization change its processes for evaluating supervisors or providing feedback on supervisors’ performance to improve safety?