Safety Human Error PDF

Safety, Accident
and
Human Error
Definitions
What is human error?
An inappropriate or undesirable human decision or

behavior that reduces or has the potential for
reducing effectiveness, safety, or human performance
Classification scheme for human error (Swain

and Guttman, 1983)
Omissionfailure to do something
Commissionperform an act incorrectly
Sequenceperform an act in the wrong order
Timingfailure to perform the act in the allotted time period
Unintentionalaccidental performance of an act (knew it
was wrong)
2
Reason (1990)
(distilled from J. Reason, Human Error, 1990)
Preliminaries: the three stages of cognitive

processing for tasks
1) planning
a goal is identified and a sequence of actions is selected to reach

the goal
2) storage
the selected plan is stored in memory until it is appropriate to

carry it out
3) execution
the plan is implemented by the process of carrying out the actions

specified by the plan
A theory of human error
Each cognitive stage has an associated form of error
slips: execution stage
lapses: storage stage
incorrect execution of a planned action

example: miskeyed command
incorrect omission of a stored, planned action
examples: skipping a step on a checklist, forgetting to restore
normal valve settings after maintenance
mistakes: planning stage
the plan is not suitable for achieving the desired goal

example: TMI operators prematurely disabling HPI pumps
Origins of error: the GEMS

model
GEMS: Generic Error-Modeling System
an attempt to understand the origins of human error
GEMS identifies three levels of cognitive task processing
skill-based: familiar, automatic procedural tasks

rule-based: tasks approached by pattern-matching from a set
of internal problem-solving rules
observed symptoms X mean system is in state Y

if system state is Y, I should probably do Z to fix it
knowledge-based: tasks approached by reasoning from first

principles
when rules and experience dont apply
GEMS and errors
Errors can occur at each level
skill-based: slips and lapses
rule-based: mistakes
usually errors of inattention or misplaced attention

usually a result of picking an inappropriate rule
caused by misconstrued view of state, over-zealous pattern matching,
frequency gambling, deficient rules
knowledge-based: mistakes
due to incomplete/inaccurate understanding of system, confirmation

bias, overconfidence, cognitive strain, ...
Error frequencies
In raw frequencies, SB >> RB > KB
61% of errors are at skill-based level

27% of errors are at rule-based level
11% of errors are at knowledge-based level
But if we look at opportunities for error, the

order reverses
humans perform vastly more SB tasks than RB, and

vastly more RB than KB
so a given KB task is more likely to result in error than a

given RB or SB task
The Automation Irony
Automation is not the cure for human error
automation addresses the easy SB/RB tasks, leaving the

complex KB tasks for the human
automation hinders understanding and mental modeling
humans are ill-suited to KB tasks, especially under stress

decreases system visibility and increases complexity
operators dont get hands-on control experience
rule-set for RB tasks and models for KB tasks are weak
automation shifts the error source from operator errors

to design errors
harder to detect/tolerate/fix design errors
Dealing with Human Error

Selection select people
with capabilities and skills

required to perform the job
Design strategies
Training tell people
what to do
Problems:
1.
2.
3.
4.
People dont like to be

told what to do
People forget or revert
to old habits
Expensive
Must be repeated
periodically and for all
new hires
Exclusion strategiesmake
it impossible to make the
error (design it out) (e.g.
put a finger activator on
punches, )
Prevention designsmake
it difficult (not impossible)
to commit the error (guard
against)
Fail-safe designsdecrease
the consequences of error
(e.g.use steel gloves when
working with cutting tools)
Accidents
How is an accident defined?
An unanticipated event which damages the system and/or

individual or affects the accomplishment of the system mission
or individual task;
It can but not necessarily result in an injury
Analysis of accidents
Nature of the injury (death, amputation, laceration, etc.)

Part of the body affected
Type of accident (struck by, caught between, etc.)
Source of injury (tools, body movement, etc.)
10
Accidents (2)
Factors contributing to accidents
Trait theories (later) such as accident proneness

Age (younger and over 60 more)
Immediate environment (noise, temperature,
light, workspace)
Equipment (controls, displays, compatibility, visibility,
guarding)
Work (pacing, physical workload, mental workload, motor
skills, etc.)
Worker (skill, experience, training, etc.)
Management (policies, safety, productivity requirements,
incentives)
Psychosocial (morale, climate, union, communication)
11
Accidents
Theories for describing/explaining accident

occurrence
1.
2.
3.
4.
Accident proneness
Accident liabilitysome people more prone to
have accident due to situation
Job demands vs. worker capability
Psychosocial
12
Factors Contributing to
Accidents
Personnel
Trait theories (later) such as
accident proneness
Age
Experience
Gender
Workload (mental/physical)
Work-rest cycles
Shift
Pacing
Procedures
Arousal, fatigue
Equipment and tools
Control/displays
Electrical hazards
Mechanical hazards
Thermal hazards
Pressure hazards
Toxic substances
Physical Environment
Job
Illumination
Noise
Temperature
Vibration
Humidity
Radiation
Fire hazards
Airborne pollutants
Social/Psychological
Environment
Management practices
Social norms
Morale
Training
Incentives
13
Human error and accident theory
Major systems accidents (normal accidents)

start with an accumulation of latent errors
most of those latent errors are human errors
latent slips/lapses, particularly in maintenance
latent mistakes in system design, organization, and

planning, particularly of emergency procedures
example: misconfigured valves in TMI
example: flowcharts that omit unforeseen paths
invisible latent errors change system reality

without altering operators models
seemingly-correct actions can then trigger accidents
Accidents are exacerbated by human errors

made during operator response
RB errors made due to lack of experience with system

in failure states
KB reasoning is hindered by system complexity and

cognitive strain
training is rarely sufficient to develop a rule base that

captures system response outside of normal bounds
system complexity prohibits mental modeling

stress of an emergency encourages RB approaches and
diminishes KB effectiveness
system visibility limited by automation and defense

in depth
results in improper rule choices and KB reasoning
Active versus Latent Failures (Reason, 1990)

Organizational
Factors
Latent Conditions
Excessive cost cutting
Inadequate promotion policies
Unsafe
Supervision
Latent Conditions
Deficient training program
Improper crew pairing
Preconditions
for
Unsafe Acts
Latent Conditions
Poor CRM
Mental Fatigue
Unsafe
Acts
Failed or
Absent Defenses
Robbing the pillar
Active Conditions
Failed to Scan Instruments
Penetrated IMC when VMC only
Accident & Injury
Crashed into side of

mountain
Hazards
Set of conditions that, together with other conditions,

will inevitably lead to an accident
Electrical
Mechanical
Pressure
Toxic substances
Radiation (300 REM kills 50% in 50 days)
Fire
Fall and trip (11ft fall kills 50%, but flight attendant survived
33,000 ft fall)
17
Managing hazards
Hazard elimination
Hazard reduction
Design for control

Lockouts
Hazard control
Substitution (lambs rather than lions)

Decoupling
Elimination of specific human errors
Reduce exposure
Isolation and containment
Damage minimization
18
Hazard management
Focus on severe hazards
Criticality = Severity X Frequency
Reduce hazards by addressing:
Source (elimination, control, limit damage)

Path (guards, task redesign)
Person (warnings, training)
Administration (rules, regulations)
19
Warnings
Purpose
Inform users or potential users of a hazard or danger through misuse

of the product
Provide information on likelihood/severity of injury from misuse
Provide information on how to decrease likelihood/severity of injury
from misuse
Remind users of danger at time and place where danger encountered
Design guidelines (minimum)
Signal word (danger, hazard, caution)

Nature of the hazard (high voltage, tightly wound part)
Consequences (can kill, lung cancer)
Instructions (stay away, do not dispose of in fire, keep away from
flame)
20
10
Warnings
Factors affecting detectability
Must catch users attention (size, shape, color, symbols, contrast,

placement, active attn getting words, durability)
Level of hazard
Dangerimmediate severe personal injury or death

Warningpossibility of severe personal injury or death
Cautionminor personal injury or property damage
Factors affecting understanding
Dont use vague or ambiguous, highly technical language (use

words that can understood at the 8th grade level)
Dont use long phrases
Be careful with symbols
Communicate consequences but dont horrify
21
Risk Perception & Warnings

!
DANGER
WARNING
CAUTION
NOTICE
22
11
Criteria for Symbols and Codes

Recognitionpeople must be able to understand the info you are
conveying
Appropriate Responsemake sure the action to take based on the symbol
is well known and understood
Coloradhere to the standards (blue and green are information, yellow is
warning, orange is hazard, red is danger)
Figure/Ground Clarity
Closureuse solid shapes with lined boundaries
SimplicityKiss principal, minimize the amount of detail, but be clear
Unity
Population Stereotypeswe expect certain symbols to mean certain
things
23
Common Warning Symbols

poison
flammable
biohazard
alert
radiation
electric shock
24
12
Common Hazard Symbols

slip hazard
prohibition
men at work
25
13

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Safety, Accident

What is human error?

An inappropriate or undesirable human decision or

Classification scheme for human error (Swain

Preliminaries: the three stages of cognitive

a goal is identified and a sequence of actions is selected to reach

the selected plan is stored in memory until it is appropriate to

the plan is implemented by the process of carrying out the actions

A theory of human error

Each cognitive stage has an associated form of error

slips: execution stage

lapses: storage stage

incorrect execution of a planned action

mistakes: planning stage

the plan is not suitable for achieving the desired goal

Origins of error: the GEMS

GEMS: Generic Error-Modeling System

an attempt to understand the origins of human error

GEMS identifies three levels of cognitive task processing

skill-based: familiar, automatic procedural tasks

observed symptoms X mean system is in state Y

knowledge-based: tasks approached by reasoning from first

when rules and experience dont apply

GEMS and errors

Errors can occur at each level

skill-based: slips and lapses

usually errors of inattention or misplaced attention

due to incomplete/inaccurate understanding of system, confirmation

In raw frequencies, SB >> RB > KB

61% of errors are at skill-based level

But if we look at opportunities for error, the

humans perform vastly more SB tasks than RB, and

so a given KB task is more likely to result in error than a

The Automation Irony

Automation is not the cure for human error

automation addresses the easy SB/RB tasks, leaving the

automation hinders understanding and mental modeling

humans are ill-suited to KB tasks, especially under stress

automation shifts the error source from operator errors

harder to detect/tolerate/fix design errors

Dealing with Human Error

with capabilities and skills

Training tell people

People dont like to be

How is an accident defined?

An unanticipated event which damages the system and/or

Nature of the injury (death, amputation, laceration, etc.)

Factors contributing to accidents

Trait theories (later) such as accident proneness

Theories for describing/explaining accident

Equipment and tools

Human error and accident theory

Major systems accidents (normal accidents)

most of those latent errors are human errors

latent slips/lapses, particularly in maintenance

latent mistakes in system design, organization, and

example: misconfigured valves in TMI

example: flowcharts that omit unforeseen paths