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Human Error
Human Error
Operator error:
Design error:
Examples
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Examples
Human Error
Human Error Probability - the ratio of
errors made with respect to the number
of opportunities for error;
P(error) = 1 - Human Reliability
Reliability Analysis
Total system reliability is a function of the
reliability of the components.
Component reliability: r = 1 - p.
r = component reliability.
p = probability of component failure.
Two kinds of systems:
Serial: Sequence of components.
Parallel: Two or more components perform
the same function (redundancy).
Reliability Analysis
Serial system reliability:
R = (r1) * (r2) (rn).
Adding a component will always decrease
reliability for a serial system.
Parallel system reliability:
R = 1 - [(1 - r1) * (1 - r2) (1-rn)]
Adding a component will always increase the
reliability of a parallel system.
Human Reliability
Operator error probability = number of
errors / number of opportunities for error.
Human reliability = 1 - operator error
probability.
Estimating human reliability:
Human Reliability
The goal of human reliability analyses is
to apply the same principles to the
human operator that we apply to the
machine/device to prevent error that
leads to system failure.
Human Error
Accident-Proneness Theories
Human Error
Stages of Human Decision-making at which
Human Error can Occur:
1. Activation/detection of system state signal
2. Observation and data collection
3. Identification of system state
4. Interpretation of situation
5. Definition of objectives
6. Evaluation of alternative strategies
7. Procedure selection
8. Procedure execution
Attention Resources
Sensory
Registration
Response
Selection
Perception
Response
Execution
Decision
Making
Working
Memory
Long-Term Memory
Perceptual Encoding
Central Processing
Responding
Basic Errors
Slip
Attentional
Failures
Lapse
Memory
Failures
Mistake
Rule-based or
Knowledge-based
Mistakes
Violation
Routine violations
Exceptional violations
Sabotage
Unintended
Action
Unsafe
Acts
Intended
Action
Decision Errors
Basic Errors
Skill Based:
Attention Failures
Memory Failures
Failures in Execution
Perceptual Based:
Visual
Auditory
Tactile
Rule Based:
Attentional Failures
Intrusion entering a dangerous area / location
Commission performing an act incorrectly
Omission failure to due something
Reversal trying to stop or undo a task already
initiated
Misordering task or set of task performed in the
wrong sequence
Mistiming person fails to perform the action within
theltime allotted
Memory Failures
Contributing Factors
Contributing Factors in Accident Causation (CFAC)
Sanders and Shaw (1988)
1. Management (organization/policies)
2. Environment (physical conditions)
3. Equipment (design)
4. Work (task characteristics)
5. Social/psychological environment (culture)
6. Worker/coworkers (personal attributes)
Typical Errors
Murphy Diagrams
Diagrammatic representations of error modes that illustrate
the underlying causes associated with cognitive decision
making tasks.
1. Activity
2.Outcome
3.Proximal Sources
4.Distal Sources
Latent Conditions
Unsafe
Supervision
Preconditions Latent Conditions
for
Unsafe Acts
Unsafe
Acts
Active Conditions
Failed or
Absent Defenses
Generic Approaches to
Minimizing Human Error
1. Personnel Selection
2. Training
3. Design