Situation awareness, human error, and organizational learning in sociotechnical systems

2019 ◽  
Vol 29 (4) ◽  
pp. 327-339
Author(s):  
Nicki Marquardt
Keyword(s):  
Organizational Learning ◽  
Situation Awareness ◽  
Human Error ◽  
Sociotechnical Systems

scholarly journals Effects of Visual Complexity Levels and Information Decluttering Methods for Cockpit Displays on Human Search Performance

2019 ◽  
Vol 63 (1) ◽  
pp. 96-100
Author(s):  
Sung Ho Kim ◽  
Ji Hwan Lee ◽  
Donggun Park ◽  
Yushin Lee ◽  
Myung Hwan Yun
Keyword(s):  
Situation Awareness ◽  
Human Error ◽  
Visual Complexity ◽  
Search Time ◽  
Human Perception ◽  
Search Performance ◽  
Design Variables ◽  
Cockpit Displays ◽  
Main Effect ◽  
Speed And Accuracy

Clutter problem of modern cockpit displays can occur frequently due to a large amount of information. So, decluttering less important information is required to minimize search time to find target information and prevent human error in interpreting display information. This study is to compare human search performance by visual complexity levels and decluttering methods of cockpit displays. Visual complexity of cockpit displays was designed to be three levels (High, medium, and low) by combining four design variables (number of stimuli, number of colors, number of icons, and variance of divisions) affecting visual complexity. A threat scoring equation was developed to determine what information to be decluttered and four decluttering methods (removal, dimming, dotting, and small sizing) were used to figure out how to declutter the information effectively. Human search performance was measured through search time of visual search task in terms of speed and number of hits of signal detection task in terms of accuracy. The main effect of visual complexity levels and the interaction effect were not significant in both search time and number of hits. Meanwhile, the main effect of decluttering methods was significant in search time. Especially, dotting was the most effective decluttering method in terms of speed and accuracy of human perception performance. The results of this study can be applied to information processing of cockpit displays and then contribute to improve pilot situation awareness.

scholarly journals An Organizational Learning Framework for Patient Safety

2016 ◽  
Vol 32 (2) ◽  
pp. 148-155 ◽  
Author(s):  
Marc T. Edwards
Keyword(s):  
Patient Safety ◽  
Organizational Learning ◽  
Human Error ◽  
High Reliability ◽  
Organizational Capabilities ◽  
Organizational Learning Theory ◽  
Culture Of Safety ◽  
Learning Framework ◽  
Operational Improvement ◽  
Learning Modes

Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.

Analyzing common approaches of accident models for risk management in socio-technical systems

2021 ◽  
Author(s):  
M. Kiwan ◽  
D.V. Berezkin ◽  
M. Raad ◽  
B. Rasheed
Keyword(s):  
Risk Management ◽  
Complex Systems ◽  
Human Error ◽  
Practical Importance ◽  
Individual Characteristics ◽  
Sociotechnical Systems ◽  
Technical Aspects ◽  
The Social ◽  
Technical Systems ◽  
Traditional Approaches

Statement of a problem. One of the main tasks today is to prevent accidents in complex systems, which requires determining their cause. In this regard, several theories and models of the causality of accidents are being developed. Traditional approaches to accident modeling are not sufficient for the analysis of accidents occurring in complex environments such as socio-technical systems, since an accident is not the result of individual component failure or human error. Therefore, we need more systematic methods for the investigation and modeling of accidents. Purpose. Conduct a comparative analysis of accident models in complex systems, identify the strengths and weaknesses of each of these models, and study the feasibility of their use in risk management in socio-technical systems. The paper analyzes the main approaches of accident modeling and their limitations in determining the cause-and-effect relationships and dynamics of modern complex systems. the methodologies to safety and accident models in sociotechnical systems based on systems theory are discussed. The complexity of sociotechnical systems requires new methodologies for modeling the development of emergency management. At the same time, it is necessary to take into account the socio-technical system as a whole and to focus on the simultaneous consideration of the social and technical aspects of the systems. When modeling accidents, it is necessary to take into account the social structures and processes of social interaction, the cultural environment, individual characteristics of a person, such as their abilities and motivation, as well as the engineering design and technical aspects of systems. Practical importance. Based on analyzing various techniques for modeling accidents, as well as studying the examples used in modeling several previous accidents and review the results of this modeling, it is concluded that it is necessary to improve the modeling techniques. The result was the appearance of hybrid models of risk management in socio-technical systems, which we will consider in detail in our next work.

scholarly journals How User-Centered Design Supports Situation Awareness for Complex Interfaces

2021 ◽  
pp. 21-35
Author(s):  
Jacob D. Oury ◽  
Frank E. Ritter
Keyword(s):  
Situation Awareness ◽  
Traffic Control ◽  
Human Error ◽  
Detection System ◽  
Error Rates ◽  
User Centered Design ◽  
Design Philosophy ◽  
System States ◽  
Machine Systems ◽  
User Centered

AbstractThis chapter moves the discussion of how to design an operation center down a level towards implementation. We present user-centered design (UCD) as a distinct design philosophy to replace user experience (UX) when designing systems like the Water Detection System (WDS). Just like any other component (e.g., electrical system, communications networks), the operator has safe operating conditions, expected error rates, and predictable performance, albeit with a more variable range for the associated metrics. However, analyzing the operator’s capabilities, like any other component in a large system, helps developers create reliable, effective systems that mitigate risks of system failure due to human error in integrated human–machine systems (e.g., air traffic control). With UCD as a design philosophy, we argue that situation awareness (SA) is an effective framework for developing successful UCD systems. SA is an established framework that describes operator performance via their ability to create and maintain a mental model of the information necessary to achieve their task. SA describes performance as a function of the operator’s ability to perceive useful information, comprehend its significance, and predict future system states. Alongside detailed explanations of UCD and SA, this chapter presents further guidance and examples demonstrating how to implement these concepts in real systems.

Apply Performance Evaluation Matrix on Investigating Human Error Events in the Main Control Room

2010 ◽  
Author(s):  
Tzu-Chung Yenn ◽  
Yung-Tsan Jou ◽  
Chiuhsiang Joe Lin ◽  
Wan-Shan Tsai ◽  
Tsung-Ling Hsieh
Keyword(s):  
Performance Evaluation ◽  
Situation Awareness ◽  
Power Plants ◽  
Human Error ◽  
Human Performance ◽  
Main Stream ◽  
Control Room ◽  
Human Errors ◽  
Wrong Decision ◽  
Evaluation Matrix

Digitalized nuclear instruments and control systems have become the main stream design for the main control room (MCR) of advanced nuclear power plants (NPPs) nowadays. Digital human-system interface (HSI) could improve human performance and, on the other hand, could reduce operators’ situation awareness as well. It might cause humans making wrong decision during an emergency unintentionally. Besides, digital HSI relies on computers to integrate system information automatically instead of human operation. It has changed the operator’s role from mainly relating operational activity to mainly relating monitoring. However, if operators omit or misjudge the information on the video display units or wide display panel, the error of omission and error of commission may occur. Therefore, how to avoid and prevent human errors has become a very imperative and important issue in the nuclear safety field. This study applies Performance Evaluation Matrix to explore the potential human errors problems of the MCR. The results show that the potential problems which would probably affect to the human performance of the MCR in advanced NPPs are multiple accidents, pressure level, number of operators, and other factors such as working environmental.

scholarly journals Visual scanning strategies in the cockpit are modulated by pilots’ expertise: A flight simulator study

PLoS ONE ◽  
2021 ◽  
Vol 16 (2) ◽  
pp. e0247061
Author(s):  
Christophe Lounis ◽  
Vsevolod Peysakhovich ◽  
Mickaël Causse
Keyword(s):  
Situation Awareness ◽  
Information Acquisition ◽  
Visual Information ◽  
Human Error ◽  
Flight Simulator ◽  
Transition Matrices ◽  
Visual Scanning ◽  
K Nearest Neighbors ◽  
Commercial Aviation ◽  
Scanning Strategies

During a flight, pilots must rigorously monitor their flight instruments since it is one of the critical activities that contribute to update their situation awareness. The monitoring is cognitively demanding, but is necessary for timely intervention in the event of a parameter deviation. Many studies have shown that a large part of commercial aviation accidents involved poor cockpit monitoring from the crew. Research in eye-tracking has developed numerous metrics to examine visual strategies in fields such as art viewing, sports, chess, reading, aviation, and space. In this article, we propose to use both basic and advanced eye metrics to study visual information acquisition, gaze dispersion, and gaze patterning among novices and pilots. The experiment involved a group of sixteen certified professional pilots and a group of sixteen novice during a manual landing task scenario performed in a flight simulator. The two groups landed three times with different levels of difficulty (manipulated via a double task paradigm). Compared to novices, professional pilots had a higher perceptual efficiency (more numerous and shorter dwells), a better distribution of attention, an ambient mode of visual attention, and more complex and elaborate visual scanning patterns. We classified pilot’s profiles (novices—experts) by machine learning based on Cosine KNN (K-Nearest Neighbors) using transition matrices. Several eye metrics were also sensitive to the landing difficulty. Our results can benefit the aviation domain by helping to assess the monitoring performance of the crews, improve initial and recurrent training and ultimately reduce incidents, and accidents due to human error.

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