INSY 3020/7976/ ENH 670

Human Error

Human Error Defined

An inappropriate or undesirable human decision or
behavior that reduces or has the potential to reduce
effectiveness, safety, or system performance
A human action/decision that exceeds system
tolerances
An action is taken that was not intended by the
actor; not desired by a set of rules or an external
observer; or that led the task or system outside its
acceptable limits (Senders & Moray, 1991, p. 25 as
cited in Proctor & van Zandt, 1994, p. 43).

Human Error
Operator error:

Due entirely to the human operator.

You cant eliminate all of these, but a good
human factors design will make these
virtually impossible.

Design error:

Due to poor design.

Examples

www.baddesigns.com

Examples

Examples

Examples

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:

Monte Carlo simulations: Describe the task,

set up a simulation of the operator, repeat
many times, estimate 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

Theories of Accident Causation

Accident-Proneness Theories

Accident proneness this theory suggests that certain

individuals are more likely to have accidents than others;
supported by statistical data; underlying assumption is that all
workers are to same job and environmental hazards
Accident liability suggests accident-proneness is limited to
specific factors (situational, age, etc.)

Job Demand vs. Worker Capability Theories

Accident liability increases when job demands exceed worker

capabilities (similar to time-ratio estimates of mental workload)
Adjustment-to-stress theory
Arousal-alertness theory

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

Information Processing Model

Wickens et al. 2004

Attention Resources

Sensory
Registration

Response
Selection

Perception

Response
Execution

Decision
Making
Working
Memory
Long-Term Memory

Perceptual Encoding

Central Processing

Responding

Human Error Taxonomy

Reason (1992)

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

Error Mechanism Categories

Decision Errors

Basic Errors

Skill Based:

Attention Failures
Memory Failures
Failures in Execution

Perceptual Based:

Visual
Auditory
Tactile

Rule Based:

Misapplication of a good rule

Application of a bad rule

Knowledge Based: Inaccurate knowledge of the system

Incomplete knowledge of the system

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

Losing ones place; forgetting intentions

Rule-based Based Mistakes

Application of a bad rule
Im in a public space in view of many people, therefore I
wont be robbed.
Misapplication of a good rule
A patient on chronic medication became concerned about
addiction and therefore deliberately stop taking the drug for
a period each year even though the drug in question was
not addictive.

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

Associated with new technologies or systems

Mode Error user thought system was in one mode when it
was actually in another.
Getting Lost Users get lost in display architectures.
Difficulty in finding the right screen or data set.
Not Coordinating Data Entries poor coordination between
multiple users inputting data into the same system.
Overload system use drains attention resources from other
equally important tasks.
Data Overload users forced to sort through a large amount
of data produced by the system in order to determine the true
nature of the situation.
Not Noticing Changes digital displays used to
communicate system changes or trends.
Automation Surprises system automation did something
user did not expect or anticipate.

Techniques & Methods

For Human Error Identification

Technique for human error rate prediction (THERP)

Hazard and operability study (HAZOP)
Skill, rule and knowledge model (SKR)
Systematic human error reduction and prediction
approach(SHERPA)
Generic error modeling system (GEMS)
Potential Human Error Cause Analysis (PHECA)
Murphy Diagrams
Critical Action and Decision Approach (CADA)
Human Reliability Management System (HRMS)
Influence modeling and assessment system (IMAS)
Confusion Matrices
Cognitive Environment Simulation (CES)

Murphy Diagrams
Diagrammatic representations of error modes that illustrate
the underlying causes associated with cognitive decision
making tasks.
1. Activity

2.Outcome

activation/detection of system state signal

observation and data collection
identification of system state
interpretation of situation
definition of objectives
evaluation of alternative strategies
procedure selection
procedure execution

3.Proximal Sources
4.Distal Sources

Murphy Diagram Example

Typical Investigation Errors

Due to Hindsight Bias

Conterfactual Reasoning Stating only what users should have

done to avoid the mishap; does not explain why users did what they
did.
Data Availability/Observability Pointing out data that could
have revealed the true nature of the situation; does not explain
which data observers used, how they used it and why they used it.
Micro-Matching Error Matching fragments of peoples overall
performance with rules and procedures taken from documentation;
does not explain why the user did what they did.
Cherry-Picking Error Identifying an over-arching condition in
hindsight (users were in a hurry) based on the outcome then
trace back through the sequence of events to confirm your
conclusions.

Human Error Investigations

Suggested Procedures

1. Do not use the outcome of a sequence of events to

assess the quality of the decisions that lead up to it
(avoid hindsight bias)
2. Dont mix elements from your own knowledge into those
of the users at the time of the mishap.
3. Dont present your knowledge to the users you
investigate. Determine what knowledge the users
utilized at the time of the mishap.
4. Recognize that consistencies and certainties of the
system are products of your hindsight, not the users
mindset at the time of the mishap.

Human Error Investigations

Suggested Procedures

5. To understand and evaluate human performance, you

must understand how the situation unfolded around
users at the time of the mishap. You must adopt a view
from inside the situation as it occurred.
6. Remember that the point of a human error investigation
is to understand why users did what they did, not to
judge them for what they did not do.

Human Error Investigations

Sources of Data / Information

Third-party and historical sources

Recordings of people performance and process
performance
Debriefings of system user participants involved
in error mishap
Purpose is to help reconstruct the situation surrounding
the users at the time of the error mishap and get their
point of view on the event.

Human Error Investigations

Debriefing & Interviewing

Approaches & Techniques:

Have users tell the story from their point of view. Do not
present them with replays or summaries to refresh
their memory
Tell the story back to them as an investigator
(checks understanding)
Have users identify critical junctures in the sequence
of events places, or short stretches of time where either
people of processes contributed critically to the
direction of subsequent events or the outcomes that
resulted

Human Error Investigations

Debriefing & Interviewing

Have them describe how the world looked to them at

each critical juncture:
what cues were observed?
what knowledge was used to deal with the situation?
what expectations did users have about how things were
going to develop?
what options did they think they had to influence events?
what other influences helped determine how they
interpreted the situation and how they would act?

Human Error Investigations

Debriefing & Interviewing
Cues

What were you seeing?

What were you focusing on?
What were you expecting to happen?
Interpretation If you had to describe the situation to a fellow user at
that point what would you have said?
Errors
What mistakes were likely at this point?
Previous
Were you reminded of any previous experiences?
Experience or Did this situation fit a standard scenario?
Knowledge
Were you trained to deal with this situation?
Were there any rules that applied clearly here?
Did you rely on other sources of knowledge?
Goals
What goals governed your actions at the time?
Were their any goal conflicts or trade-offs
Was their any time pressure?
Action
How did you judge you could influence events?
What options did you consider?
Outcome
Did the outcome fit your expectation?
Did you have to update your assessment of the situation?

Where are the holes?

What do they consist of?
Why are the holes there in the first place?
Why do the holes sizes and locations change over time?
How and why can the holes line up to produce a mishap?

Organizational Latent Conditions

Influences

Latent Conditions
Unsafe
Supervision
Preconditions Latent Conditions
for
Unsafe Acts
Unsafe
Acts

Active Conditions

Failed or
Absent Defenses

Accident & Injury

Generic Approaches to
Minimizing Human Error
1. Personnel Selection

Appropriate skills and capabilities to perform required tasks

2. Training

Helps ensure appropriate skills; can be expensive and time

consuming; people may revert to original behaviors under
stress

3. Design

Preferred method; maintainability, displays & controls,

feedback (error detection), user expectations;
categories: exclusionary, preventative, and fail-safe

Get Help From System Users

What would have helped you get the right picture of
the situation?
Would any specific training, experience, knowledge,
procedures, or cooperation, from others have helped?
If a key feature of the situation could have been
different, what would you have done differently?
Could clearer guidance from your organization, help
you make better trade-offs between conflicting goals?