Reflections on Human Error: Matters of Life and Death

1989 ◽  
Vol 33 (1) ◽  
pp. 1-7 ◽  
Author(s):  
Earl L. Wiener
Keyword(s):  
Rapid Growth ◽  
Human Error ◽  
Intervention Strategies ◽  
Human Factors Engineering ◽  
Intelligent Interfaces ◽  
Life And Death ◽  
Strategic Intent ◽  
Human Functioning ◽  
Machine Systems ◽  
Alerting Systems

The last two decades have witnessed a rapid growth in the introduction of automatic devices into aircraft cockpits, and elsewhere in human-machine systems. This was motivated in part by the assumption that when human functioning is replaced by machine functioning, human error is eliminated. Experience to date shows that this is far from true, and that automation does not replace humans, but changes their role in the system, as well as the types and severity of the errors they make. This altered role may lead to fewer, but more critical errors. Intervention strategies to prevent these errors, or ameliorate their consequences include basic human factors engineering of the interface, enhanced warning and alerting systems, and more intelligent interfaces that understand the strategic intent of the crew and can detect and trap inconsistent or erroneous input before it affects the system.

Identification of Human Errors During Early Design Stage Functional Failure Analysis

2018 ◽  
Author(s):  
Lukman Irshad ◽  
Salman Ahmed ◽  
Onan Demirel ◽  
Irem Y. Tumer
Keyword(s):  
Failure Analysis ◽  
Human Error ◽  
System Level ◽  
Design Stage ◽  
Human Factors Engineering ◽  
Human Errors ◽  
Functional Failure ◽  
Early Design ◽  
Early Design Stage ◽  
Early Design Stages

Detection of potential failures and human error and their propagation over time at an early design stage will help prevent system failures and adverse accidents. Hence, there is a need for a failure analysis technique that will assess potential functional/component failures, human errors, and how they propagate to affect the system overall. Prior work has introduced FFIP (Functional Failure Identification and Propagation), which considers both human error and mechanical failures and their propagation at a system level at early design stages. However, it fails to consider the specific human actions (expected or unexpected) that contributed towards the human error. In this paper, we propose a method to expand FFIP to include human action/error propagation during failure analysis so a designer can address the human errors using human factors engineering principals at early design stages. To explore the capabilities of the proposed method, it is applied to a hold-up tank example and the results are coupled with Digital Human Modeling to demonstrate how designers can use these tools to make better design decisions before any design commitments are made.

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.

Computational Functional Failure Analysis to Identify Human Errors During Early Design Stages

2019 ◽  
Vol 19 (3) ◽  
Author(s):  
Lukman Irshad ◽  
Salman Ahmed ◽  
H. Onan Demirel ◽  
Irem Y. Tumer
Keyword(s):  
Failure Analysis ◽  
Human Error ◽  
Human Action ◽  
System Level ◽  
Design Stage ◽  
Human Factors Engineering ◽  
Human Errors ◽  
Functional Failure ◽  
Early Design ◽  
Early Design Stages

Detection of potential failures and human error and their propagation over time at an early design stage will help prevent system failures and adverse accidents. Hence, there is a need for a failure analysis technique that will assess potential functional/component failures, human errors, and how they propagate to affect the system overall. Prior work has introduced functional failure identification and propagation (FFIP), which considers both human error and mechanical failures and their propagation at a system level at early design stages. However, it fails to consider the specific human actions (expected or unexpected) that contributed toward the human error. In this paper, we propose a method to expand FFIP to include human action/error propagation during failure analysis so a designer can address the human errors using human factors engineering principals at early design stages. The capabilities of the proposed method is presented via a hold-up tank example, and the results are coupled with digital human modeling to demonstrate how designers can use these tools to make better design decisions before any design commitments are made.

Human Factors Engineering Technology Integration into the Naval Ship Acquisition Process

1977 ◽  
Vol 21 (6) ◽  
pp. 528-531
Author(s):  
Thomas B. Malone ◽  
Phillip J. Andrews ◽  
Warren Lewis ◽  
James McGuinness
Keyword(s):  
Human Factors ◽  
Systems Engineering ◽  
Human Factors Engineering ◽  
Training Design ◽  
Design Work ◽  
Acquisition Process ◽  
Study Approach ◽  
Test And Evaluation ◽  
Surface Ship ◽  
Machine Systems

A Navy surface ship represents one of the most complex man-machine systems in existence today. Performance capabilities of personnel required in the propulsion systems, weapon systems, command-control systems, operations systems, supply systems and auxiliary systems should demand that human factors engineering (HFE) receive primary consideration in the design of ships. And yet there is no formal HFE program for ship acquisition. HFE responsibilities are not integrated with each other or with ship systems engineering efforts. There is little or no standardization of HFE methods and data beyond that provided in the design work study approach. Finally, HFE has no formal status within the ship acquisition process. The Navy Sea Systems Command recently moved to correct these problems in implementation of HFE for ships. A ship HFE technology program has been established which has as its primary objectives the integration of available applicable HFE techniques, methods, principles and data into the ship acquisition process. The effort to integrate HFE technology into the ship acquisition process began with a definition of the process itself, with emphasis on the specific events and milestones within the process. The next step entailed identification of HFE requirements appropriate for each event. HFE requirements were described in terms of activities to be completed and products to be provided to the ship design effort. HFE requirements were developed for five major functional areas: manning and training, design for operability, design for maintainability, design for habitability, and test and evaluation. After identification of HFE requirements in each of these areas, determinations were made of the degree to which available HFE technologies were appropriate to satisfy the requirements. HFE technologies consisted of HFE principles, data, methods and techniques which have been reported in the HFE literature. These technology assessments represented the best estimates of the research team concerning the applicability of available technologies for specific HFE requirements.

scholarly journals Application of Integrated Human Error Management in Human Factors Engineering Process to Nuclear Power Plant Design

2021 ◽  
Vol 6 (4) ◽  
pp. 1186-1198
Author(s):  
Kenji Mashio ◽  
Kodo Ito
Keyword(s):  
Power Plant ◽  
Nuclear Power Plant ◽  
Human Factors ◽  
Nuclear Power ◽  
Human Error ◽  
Error Management ◽  
Human Factors Engineering ◽  
Plant Design ◽  
Integrated Process ◽  
Human Errors

Integrated process of human error management in human factors engineering (HFE) process provides a systematic direction for the design countermeasures development to prevent potential human errors. The process analyzes performance influence factors (PIFs) for crew failure modes (CFMs) and human failure events (HFEvs) in human reliability analysis (HRA). This paper provides applications of the process to the event evaluation for nuclear power plant design, especially PWR. In this application, the HRA/HFE integrated process had specified further detail for PIF attributes which had not been obtained in HRA, and showed further investigations to treat how operators induced their human errors through their cognitive task process in their work environment. This application showed effectiveness of the process in order to provide design countermeasures for preventing potential human errors occurrence based on the extensive PIFs and their error forcing context in HRA.

Evaluation of Complex Human-Machine Systems Using HFE Guidelines

1994 ◽  
Vol 38 (16) ◽  
pp. 1008-1012 ◽  
Author(s):  
John M. O'Hara
Keyword(s):  
Nuclear Power ◽  
Power Plants ◽  
Health And Safety ◽  
Nuclear Regulatory Commission ◽  
Human Factors Engineering ◽  
Plant Safety ◽  
Plant Personnel ◽  
Machine Systems ◽  
Regulatory Commission ◽  
Development And Validation

The purpose of this paper is to discuss the role of human factors engineering (HFE) guidelines in the evaluation of complex human-machine systems, such as advanced nuclear power plants. Advanced control rooms will utilize human-system interface (HSI) technologies that can have significant implications for plant safety in that they will affect the ways in which plant personnel interact with the system. In order to protect public health and safety, the U.S. Nuclear Regulatory Commission reviews the HFE aspects of plant HSIs to ensure that they are designed to HFE principles and that operator performance and reliability are appropriately supported. Evaluations using HFE guidelines are an important part of the overall review methodology. The Advanced HSI Design Review Guideline (DRG) was developed to provide these review criteria. This paper will address (1) the issues associated with guideline-based evaluations, (2) DRG development and validation, and (3) the DRG review procedures.

Topics in Inclusive Design for the Graduate Human Factors Engineering Curriculum

2017 ◽  
Vol 61 (1) ◽  
pp. 403-406
Author(s):  
Clive D’Souza
Keyword(s):  
Human Factors ◽  
Lessons Learned ◽  
Inclusive Design ◽  
Human Factors Engineering ◽  
Engineering Curriculum ◽  
User Centered Design ◽  
Full Spectrum ◽  
Human Functioning ◽  
Disability Prevalence ◽  
And Performance

The confluence of demographic trends in aging and disability prevalence, increased expectations among workers and consumers with and without impairments, and greater reliance on complex yet pervasive technologies (e.g., automation, internet of things) has resulted in an increased emphasis on designing for human-system performance and accommodation across the full spectrum of human abilities. Inclusive design or universal design (UD) is one of the few user-centered design paradigms that advocate consideration for the full spectrum of human abilities, including individuals with and without disabilities. A graduate-level course was developed and implemented to introduce ergonomics and human factors students to the UD paradigm and to UD goals and principles using select academic and non-academic readings, and assignments related to multivariate statistics, field observations, and design of experiments. The course placed an emphasis on the fundamentals and research base in ergonomics in relation to UD research and practice, viz., topics related to variability in human functioning and performance associated with anthropometry, biomechanics, perception and cognition. Alongside the motivations for the course, this paper provides an overview of the course objectives, topics covered, and some early lessons learned.

Control Room Human Factors Assessment at a Bulgariannuclear Power Plant

1995 ◽  
Vol 39 (15) ◽  
pp. 1043-1047
Author(s):  
Stephen A. Fleger ◽  
Michael R. McWilliams
Keyword(s):  
Power Plant ◽  
Nuclear Power Plant ◽  
Human Factors ◽  
Nuclear Power ◽  
Human Error ◽  
Human Factors Engineering ◽  
Control Room ◽  
Energy Agency ◽  
Reactor Control ◽  
Control Rooms

This paper presents the results of a preliminary assessment of human factors concerns associated with the six reactor control rooms at the Kozloduy Nuclear Power Plant in Bulgaria. This initiative was sponsored by the Committee of Energy, Bulgaria, as part of a multi-faceted project that examined emergency operating procedures, training, and risk-based maintenance practices at Kozloduy. The goal of the study was to determine the overall adequacy of the interfaces, from a human error prevention perspective, between operator and plant processes as found in the control rooms, and if warranted, to develop a program plan for conducting subsequent detailed control room design reviews. The need for this study was stimulated in part by a report prepared by the International Atomic Energy Agency which found that WWER-440 model 230 reactor control rooms were in urgent need of human factors attention. This paper summarizes the findings from the human factors portion of the study, and discusses potential concerns associated with applying U.S. developed human factors engineering criteria to an eastern European nuclear power plant.

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