Error mode prediction

Korea Institute of Energy Research, Sŏul, Seoul, South Korea
Ergonomics (Impact Factor: 1.56). 12/1999; 42(11):1457-71. DOI: 10.1080/001401399184811
Source: PubMed


The study of accidents ('human errors') has been dominated by efforts to develop 'error' taxonomies and 'error' models that enable the retrospective identification of likely causes. In the field of Human Reliability Analysis (HRA) there is, however, a significant practical need for methods that can predict the occurrence of erroneous actions--qualitatively and quantitatively. The present experiment tested an approach for qualitative performance prediction based on the Cognitive Reliability and Error Analysis Method (CREAM). Predictions of possible erroneous actions were made for operators using different types of alarm systems. The data were collected as part of a large-scale experiment using professional nuclear power plant operators in a full scope simulator. The analysis showed that the predictions were correct in more than 70% of the cases, and also that the coverage of the predictions depended critically on the comprehensiveness of the preceding task analysis.

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Available from: Erik Hollnagel, Oct 26, 2015
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    • "Furthermore , Woods et al. (2010) argued that it is the investigation of the cognition and behaviour of individuals not the attribution of error that will lead to increased understandings to promote useful changes for reducing the potential for disasters. Ergonomics practitioners have previously faced the accusation of using research techniques that lack a theoretical underpinning (Hollnagel et al., 1999; Ponomarenko, 2004). Whilst attempts have been made to base error taxonomies on theory, such as Shappell and Wiegmann's (2000) Human Factors Analysis and Classification System method (which draws heavily on Reason's (1990) latent failure theory of error), the underlying psychological mechanisms causing errors to occur are not fully considered and the method is still a classification scheme, though arguably a sophisticated one. "
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    ABSTRACT: Although human error remains a dominant issue in aviation research, methods that predict human error have been criticised for not providing adequate causal explanations, rather they have focused on classification. The concept of Schemata has prevailed in the literature and has been shown to describe the contextual causes of human error. The purpose of this paper is to review the recent error literature and demonstrate that Schema Theory (as incorporated in the Perceptual Cycle framework) offers a compelling causal account of human error. Schema Theory offers a system perspective with a focus on human activity in context to explain why apparently erroneous actions occurred, even though they may have appeared to be appropriate at the time. This is exemplified in a case study of the pilots’ actions preceding the 1989 Kegworth accident. Schema Theory is presented as a promising avenue for further exploration into the context of human error in aviation.
    Full-text · Article · Feb 2012 · Safety Science
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    • "We certainly sympathise with this call and it is central to the aims of the present paper. In analysing the Cognitive Reliability and Error Analysis Method (CREAM), Hollnagel et al. (1999) "
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    ABSTRACT: This paper reports on the theoretical and empirical developments for an error prediction methodology called task analysis for error identification (TAFEI). Other researchers have noted the need for theoretically driven approaches that are able to provide practical utility in error prediction. Theoretical developments include the concept of "rewritable routines", which describe the loop between cognitive processing, action and devices states. This has been proposed as a way of unifying ideas from systems theory and cognitive psychology. The empirical research shows that TAFEI is superior to heuristic methods, which supports the idea that structured methods assist in error prediction. The validation study shows that TAFEI reaches acceptable levels in terms of test-retest reliability and concurrent validity. It is believed that the method has reached a level of maturity after 10 years of development work. This is demonstrated by the many uses to which the method has been put, including that of a design tool.
    Full-text · Article · Aug 2005 · Ergonomics
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    • "The SHERPA method (systematic human error reduction and prediction approach) (Embrey, 1986) classifies task information processing according to different human behavioural characteristics, adapted from Rasmussen's model: skill-based processing, rule-based causal processing, rule-based action processing and knowledge-based processing. On the other hand, the CREAM method (cognitive reliability and error analysis method) (Hollnagel et al., 1997) analyses human errors taking into account other human behavioural aspects: cognitive functions such as observation, interpretation , planning, or execution, and their relations with cognitive activities such as coordination, communication, comparison, diagnosis, identification, or regulation. Other methods, such as the APRECIH method (French acronym for Preliminary Analysis of Consequences of Human Unreliability), focus on the consequence assessment of human behavioural deviations independently of the probabilities of the occurrence of human errors (Vanderhaegen, 1999). "
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    ABSTRACT: For the design of most technical systems a desirable safe field of use is calculated from systems technical constraints, and expectations of human capacities and limitations. Performance incursions outside the safe field are then limited by means of hard-protections, instructions, education, and regulations. However, once in service, the socio-technical conditions of work create conditions for performance to migrate and stabilise outside the expected safe field of use. The stabilisation of migration results from a compromise between global performance improvement, individual additional advantages, and apparent risk control. This paper proposes a double modelling approach to such migrations, first in terms of a cognitive model of the production of migrations, and second in terms of a mathematical safety analysis of severity and consequences. Both approaches lead to the emergence of methodologies in order to take BTCU into account during design. Conclusions highlight the impossibility of avoiding such in service migrations of use, and advocate for an early consideration of potential migrations in order to improve the robustness of safety analysis techniques. The field example chosen for demonstration is the design and use of a rotary press.
    Full-text · Article · Mar 2003 · Safety Science
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