HUMAN ERROR Research Papers - Academia.edu (original) (raw)

High Reliability Organisation (HRO) and Resilience Engineering (RE) are two research traditions which have attracted a wide and diverse readership in the past decade. Both have reached the status of central contributions to the field of... more

High Reliability Organisation (HRO) and Resilience Engineering (RE) are two research traditions which have attracted a wide and diverse readership in the past decade. Both have reached the status of central contributions to the field of safety while sharing a similar orientation. This is not without creating tensions or questions, as expressed in the call of this special issue. The contention of this article is that these two schools introduce ways of approaching safety which need to be reflected upon in order to avoid simplifications and hasty judgments about their relative strength, weaknesses or degree of overlapping. HRO has gained strength and legitimacy from (1) studying ethnographically, with an organisational angle, high-risk systems, (2) debating about principles producing organisation reliability in face of high complexity and (3) conceptualising some of these principles into a successful generic model of " collective mindfulness " , with both practical and theoretical success. RE has gained strength and legitimacy from (1) harnessing then deconstructing, empirically and theoretically, the notion of 'human error', (2) argued for a system (and complexity) view and discourse about safety/accidents, (3) and supported this view with the help of (graphical) actionable models and methods (i.e. the engineering orientation). In order to show this, one has to go beyond the past 10 years of RE to include a longer time frame going back to the 80s to the early days of Cognitive Engineering (CE). The approach that is followed here includes therefore a strong historical orientation as a way to better understand the present situation, profile each school, promote complementarities while maintaining nuances.

Over the past two decades, the 'new view' has become a popular term in safety theory and practice. It has however also been criticised, provoking division and controversy. The aim of this article is to clarify the current situation. It... more

Over the past two decades, the 'new view' has become a popular term in safety theory and practice. It has however also been criticised, provoking division and controversy. The aim of this article is to clarify the current situation. It describes the origins, ambiguities and successes of the 'new view' as well as the critiques formulated. The article begins by outlining the origins of this concept, in the 1980s and 1990s, from the cognitive (system) engineering (CSE) school initiated by Rasmussen, Hollnagel and Woods. This differed from Reason's approach to human error in this period. The article explains how Dekker, in the early 2000s, translates ideas from the CSE school to coin the term 'new view', while also developing, shortly after, an argument against Reason's legacy that was more radical and critical than his predecessors'. Secondly, the article describes the ambiguities associated with the term 'new view' because of the different programs that have derived from CSE (Resilience Engineering-RE then Safety II, Safety Differently, Theory of Graceful Extensibility). The text then identifies three programs by different thinkers (methodological, formal and critical) and Dekker's three eclectic versions of the 'new view'. Thirdly, the article discusses the success of the CSE and RE school, showing how it has strongly resonated with many practitioners outside the academic world. Fourthly, the objections raised within the field of human factors and system safety but also from different traditions (e.g., system safety engineering with Leveson, sociology of safety with Hopkins) are introduced, and discussed.

The correct functioning of interactive computer systems depends on both the faultless operation of the device and correct human actions. In this paper, we focus on system malfunctions due to human actions. We present abstract principles... more

The correct functioning of interactive computer systems depends on both the faultless operation of the device and correct human actions. In this paper, we focus on system malfunctions due to human actions. We present abstract principles that generate cognitively plausible human behaviour. These principles are then formalised in a higher-order logic as a generic , and so retargetable, cognitive architecture, based on results from cognitive psychology. We instantiate the generic cognitive architecture to obtain specific user models. These are then used in a series of case studies on the formal verification of simple interactive systems. By doing this, we demonstrate that our verification methodology can detect a variety of realistic, potentially erroneous actions, which emerge from the combination of a poorly designed device and cognitively plausible human behaviour.

Risk is defined as the probability of a specific adverse event occurring within a specific period, while Quantitative risk assessment (QRA) is the development of a quantitative estimate of risk based on engineering evaluation and... more

Risk is defined as the probability of a specific adverse event occurring within a specific period, while Quantitative risk assessment (QRA) is the development of a quantitative estimate of risk based on engineering evaluation and mathematical techniques by combining estimate of incident consequences and frequencies. In view of the increase in the use of railways as the mode of transportation for hazardous materials throughout the world, the associated risk analysis should be taken into concern. In this study, the failure frequency of the transportation of ammonia from the Petronas fertilizers Kedah (PFK) plant in Gurun (Northern part of Peninsular Malaysia), to the Chemical Company Malaysia (CCM) fertilizer's facilities in Port Klang (South-western part of Peninsular Malaysia) was evaluated by incorporating the human error assessment. The study highlighted the importance of human error contributions in the failure frequency analysis and its impact on the selected failure scenarios. Besides, it also shows that the application of the human error assessment and reduction technique (HEART), which is a useful human reliability analysis tool, should be used in parallel with the fuzzy arithmetic approach to reduce the uncertainties involved in the estimation of human error probabilities, and hence, to reduce the likelihood of incorrect risks estimates being assessed. The results suggested that the commonly applied approach in quantitative risk assessments, which only consider equipment failures in the failure frequency estimations, are clearly an underestimate of the potential causes of failures leading to hazardous material releases, and hence, the calculated risks based do not reflect the actual risks. © 2008 American Institute of Chemical Engineers Process Saf Prog, 2009

The paper offers a social science perspective on some of the assumptions and abstractions implicit in the semantic web vision in one bio-medical domain. The focus here is on the more persistent semantic and systemic alignment issues in... more

The paper offers a social science perspective on some of the assumptions and abstractions implicit in the semantic web vision in one bio-medical domain. The focus here is on the more persistent semantic and systemic alignment issues in the context of neuro-psychiatric disease, as experienced by Grid projects working in this domain in the UK, EU and US, where the opportunities and the challenges of integration have been particularly evident.

Construction accident investigation techniques and reporting systems identify what type of accidents occur and how they occurred. Unfortunately, they do not properly address why the accident occurred by identifying possible root causes,... more

Construction accident investigation techniques and reporting systems identify what type of accidents occur and how they occurred. Unfortunately, they do not properly address why the accident occurred by identifying possible root causes, which is only possible by complementing these techniques with theories of accident causation and theories of human error. The uniqueness of the construction industry dictates the need to tailor many of the contemporary accident causation models and human error theories. This paper presents ...

Abstract—Use of information technology has become com-monplace in healthcare. In an ideal world a patient always gets first class treatment and everything goes smoothly and as planned. Applications of information technology are created to... more

Abstract—Use of information technology has become com-monplace in healthcare. In an ideal world a patient always gets first class treatment and everything goes smoothly and as planned. Applications of information technology are created to help the hospital staff ...

La valutazione della fidatezza degli schemi elettrici di potenza è lasciata all'esperienza e alla conoscenza del singolo progettista. Per questa ragione, troppo frequentemente, gli schemi delle infrastrutture, quali ospedali, aeroporti,... more

La valutazione della fidatezza degli schemi elettrici di potenza è lasciata all'esperienza e alla conoscenza del singolo progettista. Per questa ragione, troppo frequentemente, gli schemi delle infrastrutture, quali ospedali, aeroporti, stadi e teatri, grattacieli, gallerie autostradali sono progettati senza neppure la percezione dell'esistenza di concetti che sono invece a fondamento della progettazione nei più evoluti contesti industriali. Tra questi, inoltre, lo scambio di informazioni è abbastanza rara: il mondo ferroviario, navale, aerospaziale, nucleare, le società di distribuzione di energia, la ricerca universitaria, il settore petrolifero, il mondo della tecnologia informatica costituiscono dei contesti di eccellenza, di fatto inaccessibili a coloro che non vi appartengono. Una classificazione degli schemi elettrici sulla base di criteri condivisi, con specifico riferimento alla fidatezza, potrebbe aiutare a condividere e a diffondere questa cultura, oltre che a premiare la ricerca e sviluppo dei migliori fabbricanti. Nell'articolo si traccia uno schema di classificazione e si avanzano le ipotesi dei criteri di validazione.

The Human Factors Analysis and Classification System (HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing the human causes of aviation accidents.... more

The Human Factors Analysis and Classification System (HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing the human causes of aviation accidents. Based on Reason's (1990) model of latent and active failures, HFACS addresses human error at all levels of the system, including the condition of aircrew and organizational factors. The purpose of the present study was to assess the utility of the HFACS framework as an error analysis and classification tool outside the military. The HFACS framework was used to analyze human error data associated with aircrew-related commercial aviation accidents that occurred between January 1990 and December 1996 using database records maintained by the NTSB and the FAA. Investigators were able to reliably accommodate all the human causal factors associated with the commercial aviation accidents examined in this study using the HFACS system. In addition, the class...

Safe surgical practice requires a combination of technical and nontechnical abilities. Both sets of skills can be impaired by intra-operative stress, compromising performance and patient safety. This systematic review aims to assess the... more

Safe surgical practice requires a combination of technical and nontechnical abilities. Both sets of skills can be impaired by intra-operative stress, compromising performance and patient safety. This systematic review aims to assess the effects of intra-operative stress on surgical performance.A systematic search strategy was implemented to obtain relevant articles. MEDLINE, EMBASE, and PsycINFO databases were searched, and 3,547 abstracts were identified. After application of limits, 660 abstracts were retrieved for subsequent evaluation. Studies were included on the basis of predetermined inclusion criteria and independent assessment by 2 reviewers.In all, 22 articles formed the evidence base for this review. Key stressors included laparoscopic surgery (7 studies), bleeding (4 studies), distractions (4 studies), time pressure (3 studies), procedural complexity (3 studies), and equipment problems (2 studies). The methods for assessing stress and performance varied greatly across studies, rendering cross-study comparisons difficult. With only 7 studies assessing stress and surgical performance concurrently, establishing a direct link was challenging. Despite this shortfall, the direction of the evidence suggested that excessive stress impairs performance. Specifically, laparoscopic procedures trigger greater stress levels and poorer technical performance (3 studies), and expert surgeons experience less stress and less impaired performance compared with juniors (2 studies). Finally, 3 studies suggest that stressful crises impair surgeons' nontechnical skills (eg, communication and decision making).Surgeons are subject to many intra-operative stressors that can impair their performance. Current evidence is characterized by marked heterogeneity of research designs and variable study quality. Further research on stress and performance is required so that surgical training and clinical excellence can flourish.

This paper investigates the contribution of a human modeling and simulation software in two different applications: workstation in a medical products industry and a costumer service counter. This study examines its application in sectors... more

This paper investigates the contribution of a human modeling and simulation software in two different applications: workstation in a medical products industry and a costumer service counter.
This study examines its application in sectors iin which these techniques had not been well developed yet. The same way, it can contribute to the application in other areas as well.
The results achieved were: evaluations of the visual fields, determination of workplaces’ physical characteristics, visualization of reach envelopes and improving communications between different people involved in the process, reduce the time spent on the process, and especially, preliminary considerations of human factors.

Back cover text: Real Social Science presents a new, hands-on approach to social inquiry. The theoretical and methodological ideas behind the book, inspired by Aristotelian phronesis, represent an original perspective within the social... more

Back cover text: Real Social Science presents a new, hands-on approach to social inquiry. The theoretical and methodological ideas behind the book, inspired by Aristotelian phronesis, represent an original perspective within the social sciences, and this volume gives readers for the first time a set of studies exemplifying what applied phronesis looks like in practice. The reflexive analysis of values and power gives new meaning to the impact of research on policy and practice. Real Social Science is a major step forward in a novel and thriving field of research. This book will benefit scholars, researchers, and students who want to make a difference in practice, not just in the academy. Its message will make it essential reading for students and academics across the social sciences.

The 2003 invasion of Iraq by the United States yielded no evidence to Saddam's possession of weapons of mass destruction. This paper aims to analyze the intelligence utilized by the U.S. Bush Administration to justify the invasion of... more

The 2003 invasion of Iraq by the United States yielded no evidence to Saddam's possession of weapons of mass destruction. This paper aims to analyze the intelligence utilized by the U.S. Bush Administration to justify the invasion of Iraq, and whether this intelligence collection process was biased.

The purpose of this paper is to identify the threats that exist in Healthcare Information Systems (HIS). The study has been carried out in three different departments namely, Information Technology Department (ITD), Medical Record... more

The purpose of this paper is to identify the threats that exist in Healthcare Information Systems (HIS). The study has been carried out in three different departments namely, Information Technology Department (ITD), Medical Record Department (MRD) and X-Ray Department in one of the leading government supported hospital in Malaysia. The hospital was equipped with Total Hospital Information System (THIS) environment. The data were collected using in-depth structured interviews. The study identified 22 types of threats according to major threat categories based on ISO/IEC 27002 (ISO 27799:2008). The result shows the most critical threat for the THIS is the power failure. In addition, acts of human error or failure threat also show high frequency of occurrence. The contribution of the paper will be categorization of threats in HIS and can be used to design and implement effective security systems and policies in healthcare setting.