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- Introduction
This session will introduce the topic of human erroneous action and
the concepts needed to guide the explorations of the complex issues
associated with the human contribution to system breakdowns. The problems
in defining "human errors" will be discussed, as well as
the view that erroneous actions are an important form of creativity
and learning about a system. Specific topics will be the complexity
and cognition behind human erroneous action, and the need for anticipating
and modelling human erroneous action.
- The analysis of accidents and mishaps
An important part of giving meaning to past accidents and mishaps
consists of methodological approaches to incident analysis. The retrospective
use of the Cognitive Reliability and Error Analysis Method (CREAM)
will be introduced and illustrated by examples. After system disaster,
a human operator can always be found somewhere in the rubble. One
of the largest challenges in the investigation of the causes of a
breakdown is a consideration of the organisational and cognitive factors
that shaped the human actions. The use of a concrete example of an
aircraft accident will illustrate the possibility of analysing past
mishaps, despite its inherent difficulty and complexity.
- The context of erroneous actions
The organisation of which operators are part plays an important role
in shaping the actions of local operators, through the resources it
provides and double binds it creates. New technology may also fundamentally
exacerbate cognitive demands and change the type and consequences
of human erroneous action. This has been captured by terms such as
clumsy automation, multi-mode systems, keyhole effects, etc., that
can contribute to breakdowns in human-machine interaction. In the
Scandinavian tradition, this has been expressed as the Man-Technology-Organisation
(MTO) concept, which often is a prime determiner of how erroneous
actions manifest themselves. Similarly, physical and functional barriers
may be used to prevent the propagation of the consequences of erroneous
actions.
- Predicting system failures
Human erroneous actions have always been seen as a major (and in
some industries growing) threat to system safety. There is a long
history of predicting human erroneous actions and their consequences
for system integrity, especially in nuclear power. Here, we will discuss
traditional methods of risk assessment, their shortcomings, and introduce
models that provide new ways forward. The predictive use of the Cognitive
Reliability and Error Analysis Method (CREAM) will be described
- Conclusions and summary
In the context of cognitive systems engineering, erroneous actions
can be seen both as a consequence of coping with complexity and
as an indication of the quality of the tools provided. The course
will end by providing a larger perspective on erroneous actions
as a potential failure not only of the people at the sharp end (operators,
pilots, users), but also of people at the blunt end (designers,
managers, etc.).
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