ArticlePDF Available

USING OBSERVATIONAL STUDY AS A TOOL FOR DISCOVERY: UNCOVERING COGNITIVE AND COLLABORATIVE DEMANDS AND ADAPTIVE STRATEGIES

Authors:

Figures

Content may be subject to copyright.
1
USING OBSERVATIONAL STUDY AS A TOOL FOR DISCOVERY:
UNCOVERING COGNITIVE AND COLLABORATIVE DEMANDS AND
ADAPTIVE STRATEGIES*
Emilie M. Roth
Roth Cognitive Engineering
Brookline, MA
Emily S. Patterson
Institute for Ergonomics, Ohio State University
Midwest Patient Safety Center of Inquiry, Veteran’s Administration
Columbus, OH
INTRODUCTION
One of the primary strengths of naturalistic observations is that they support a discovery
process (Woods, 1995; Mumaw, Roth, Vicente and Burns, 2000). They serve to draw attention
to significant phenomena and suggest new ideas whose validity and generality can then be
evaluated through additional studies.
Field observations afford the opportunity to gain a realistic view of the full complexity of the
work environment and empirically grounded hypotheses for how interventions could impact the
nature of work in that setting. They enable researchers to uncover and document cognitive and
collaborative demands imposed by a domain, the strategies that practitioners have developed in
response to those demands, and the role that existing artifacts play in meeting domain demands.
The results can be used to point to and guide the development of new types of support systems.
In this paper, two studies are used to illustrate this approach. In the first case (Roth, Malsch
& Multer, 2001), a series of field observations and structured interviews were conducted at train
dispatching centers to inform the design of a “data link” technology intended to improve
performance by reducing communications on an overloaded audio channel. In the second case
(Roth & O’Hara, 1999), observations of the use of advanced human-system interfaces in a
nuclear power plant simulator were conducted prior to implementation in the plant in order to
uncover and document unanticipitated changes in cognitive and collaborative demands as a result
of the introduction of the new technology.
The studies illustrate the methods used in conducting and analyzing the results of
observational studies, as well as the kinds of insights that can be gained from observational
studies.
OVERVIEW OF METHODOLOGY
Naturalistic observation studies employ a methodology similar in approach to other
ethnographically derived methods (e.g., Jordan & Henderson, 1995; Nardi, 1997) and the
European field study tradition (De Keyser, 1990; Heath and Luff, 2000). Observers are placed
in the actual work setting to observe and interview domain practitioners as opportunities arise.
Particular attention is placed on detailed capture of illustrative incidents that provide concrete
* Presented at the 5th Naturalistic Decision Making Conference held in Sweden, May, 2000, in press.
2
examples of the kinds of complexities that can arise in the environment, the kinds of cognitive
and collaborative strategies and facilitating activities that domain practitioners use to handle
these situations, and how existing artifacts are tailored in order to meet situation demands. These
illustrative incidents may be examples of practitioner performance in routine situations that arise
often, or they may represent a response to a relatively rare occurrence (e.g., equipment
malfunction, accident) that arises during the observational study.
Exploratory observational studies contrast to other scientific methods in that the focus of the
observations and analysis is on discovery rather than hypothesis testing. Different analysts
looking at the same domain might very well focus on different aspects and uncover different
insights if they draw on very different conceptual frameworks in selecting what is ‘interesting’ to
capture. In this type of research what matters is not 'reliability' -- would different analysts
working independently have focused on the same observations? But rather how 'generative' the
work is -- are the results insightful and productive with respect to pointing to sources of
performance problems and opportunities for improvement?
Figure 1 provides a graphic representation of the data analysis and abstraction process
used to derive generalizations from the specific observations (cf., Hollnagel et al., 1981,
Patterson and Woods, 2001). Observations and analyses are guided by (1) the questions that the
study is intended to address, (2) the sample of practitioners and activities observed and (3) the
conceptual frameworks that the observers bring to bear.
Figure 1. Conceptual frameworks and study questions that define what is ‘interesting’ and thus
guide observations and the data analysis and abstraction process.
Conceptual Frameworks
StudyQuestions
Distributed cognition
Common ground in communication
Supervisory control of automation
...
Data Analysis and Abstraction
R
a
w
Data:
notes, audio/video tapes:
Corpus of Illustrative Cases
Patterns Across Cases
Generalized Despriptions,
Principles, Conceptual Frameworks
What are cognitive and collaborative demands?
What strategies have developed to cope with demands?
...
multiple domain practioners
multiple techniques (e.g., observation, interviews)
mult iple ses sions
mult iple ob servers
3
Conceptual frameworks play an important role in guiding observations and analyses (cf.
Lipshitz, this volume). In the studies described below observations and analyses are informed
by bodies of knowledge about the interaction of humans and supporting artifacts in complex,
socio-technical systems from the field of cognitive engineering and related behavioral and social
sciences (e.g., theory of distributed cognition, role of common ground in multi-agent
communication, principles of human automation interaction and the consequences of clumsy
automation).
These conceptual frameworks guide the identification of ‘interesting’ cases to capture. They
enable tractability in data collection, both in terms of the amount of time spent observing (on the
order of days instead months) and the level of detail of what is recorded and analyzed (sequences
of events rather than second by second behavioral and verbal interactions).
Conceptual frameworks also support the analysis process used to identify common patterns
across a corpus of illustrative cases, and to draw generalizations that have applicability beyond
the particular cases examined. These analysis stages correspond to the levels of analysis that
Lipshitz (this volume) refers to as ‘paraphrasing’ and ‘theorizing’.
It should be pointed out that conceptual frameworks not only serve as a starting point for
observation and analysis – a framework by which to interpret and aggregate findings, they are
also an output of the analysis process. The general descriptions, principles and conceptual
frameworks that emerge from the analysis of an observational study are expressed at a level of
abstraction that allow across domain comparison and application. The results of observational
studies can be used to support, expand, refine, or refute existing conceptual frameworks. They
can also be used to generate new conceptual frameworks and theories.
The differences in goals of exploratory observational studies, as contrasted with studies
designed to test a specific hypothesis, leads to different study design considerations. For
example, an important consideration in a study designed for hypothesis testing is to control the
conditions of observation and minimize variability (both with respect to the range of situations
observed and with respect to what observers record). In contrast, because the focus of
exploratory observational studies is on discovery, the objective is to broaden the set of
observations and conceptual frameworks brought to bear by observers in order to maximize the
opportunity for uncovering interesting findings and drawing productive insights.
Several techniques are used to broaden the set of observations and conceptual frameworks
brought to bear. These include:
broadly sampling domain practice (e.g., multiple shifts, multiple practitioners at multiple
levels of experience; multiple sites)
use of multiple converging techniques (e.g., field observations, structured interviews,
questionnaires)
use of multiple observers who are likely to bring different conceptual frameworks
Another important concern in performing observational studies is the accuracy of the
observations and their interpretation. Several strategies are used to guard against errors and
biases. First, observers take advantage of opportunities to continuously ‘bootstrap’ their
understanding of the domain complexities, iteratively refining their notion of what is ‘interesting’
to collect and analyze (Lipshitz, this volume). Each observation provides a potential opportunity
to generate new conjectures as well as test conjectures generated in prior observations. This
4
approach allows the discovery of critical factors not predicted in advance as well as the
opportunity to discard early conjectures that are not supported by later observations. The ability
to sample the domain of practice broadly (multiple practitioners, multiple levels of domain
expertise, multiple session, multiple sites) provides an opportunity to look for commonalities
across cases as well as divergences (contrasting cases) that reveal interesting insights.
A second technique to promote accurate interpretation is to compare the insights and
perspective of multiple observers. It is common to hold meetings immediately following an
observation period where the multiple observers share their observations and interpretations.
This reduces the risk of forgetting critical details that are ‘in the head’ of the observer but not
recorded in the ‘raw data’, and improves data reliability by allowing multiple observers to
contrast their interpretations of events while their memories are still fresh and it is still possible
to pursue additional data to resolve ambiguities or differences in interpretation (e.g., by
conducting follow-up interviews with the domain practitioners that were the subject of the
observations).
The ultimate criterion in evaluating the results of an observational study is that once the
insights are made and pointed out, that other analysts (or more relevantly the domain
practitioners themselves) would agree with the findings and interpretation. A common practice is
to present the results of the study to domain practitioners (either in the form of a report or a
presentation) and solicit feedback on the accuracy of the base observations and their
interpretations.
The two studies summarized below provide concrete illustrations of this methodological
approach.
STUDY 1: INFORMING THE DESIGN OF NEW TECHNOLOGY
New technologies often fail to have the desired effects on human performance when
introduced into actual complex, socio-technical settings. This first study illustrates how a series
of observations and interviews uncovered cognitive and collaborative demands and adaptive
strategies with current communication technology that had implications for the design of a new
“data link” communication technology for train dispatching (Roth, Malsch, Multer & Coplen,
1999; Roth, Malsch & Multer, 2001).
Currently, voice radio is the primary means of communication between Railroad Dispatchers
and the railway workers they interact with (e.g., Locomotive Engineers; Maintenance of Way
Workers). The radio channels are overloaded however, creating a data overload situation for
Train Dispatchers. The railroad industry has been examining the use of data link technology to
communicate in place of or in addition to voice radio communication. The guiding questions for
this study were:
1. What activities could be supported more effectively with data link digital
communication systems?
2. What features of the existing technology are important to effective dispatcher
performance and therefore need to be considered when deploying new technology?
The study combined field observations at dispatch centers with structured interviews with
experienced dispatchers. In the first phase, Railroad Dispatchers were observed as they went
about their job in a railroad dispatch center that primarily handled passenger trains. Two
observers participated. Each observer sat next to a different railroad dispatcher and observed the
communications he or she engaged in, and the train routing and track management decisions that
5
were made. The observer asked the dispatcher questions during low workload periods.
Questions were guided by a checklist of pre-defined topics and by the observed behavior.
A total of 8 dispatchers were observed across two shifts. Observations included high
workload early morning rush-hour periods, lower workload mid-day periods, and shift turnovers.
Phase 2 consisted of structured interviews with experienced railroad dispatchers and related
personnel from the same railroad dispatch. Phase 3 involved field observations at a second
dispatch center that primarily handled freight trains. This was to assess the generality of the
results obtained at the first dispatch center. The fourth phase involved a second set of field
observations at the same dispatch center observed during Phase 1. This was to verify and expand
on the results obtained in the previous three phases. In general, the results from each phase
confirmed and extended the results from the previous phase.
Uncovering the Role of Radio ‘Party-Line’ in Facilitating Railroad Dispatching
Railroad dispatching involves extensive communication and coordination among
individuals distributed in time and space. In a typical railroad dispatch center, there are multiple
dispatchers working in parallel, each responsible for different territories, who must coordinate
with others in order to manage track usage efficiently and minimize train delays. Observations
were therefore guided by concepts from the distributed cognition, common ground, and
distributed planning literatures. The observations revealed the cognitive and collaborative
demands and the cooperative planning and error detection strategies that dispatchers have
developed with the current technology.
What makes railroad dispatching cognitively difficult is the need to deal with unplanned
demands on track usage (e.g., the need to accommodate unscheduled trains and requests for time
on the track for maintenance work), and the need for dynamic re-planning in response to
unanticipated events (e.g., train delays, track outages). The observational study revealed that
successful performance depends on the ability of dispatchers to monitor train movement beyond
their territory, anticipate delays, balance multiple demands placed on track usage, and make rapid
decisions. This requires keeping track of where trains are, whether they will reach destination
points (meets, stations) on time or will be delayed, and how long the delays will be.
To meet these demands, dispatchers have developed information-gathering strategies that
allow them to anticipate requirements for changes to schedules and planned meets early so as to
have time to take compensatory action. Many of these strategies depend on communication and
coordination among individuals distributed across time and space. This includes coordination
among dispatchers managing abutting territories within a dispatch center as well as coordination
among the various crafts within a railroad (e.g., locomotive engineers, train masters, dispatchers,
and roadway personnel).
One of the most salient findings was that railroad dispatchers took advantage of the
broadcast/’party-line’ feature of radio to anticipate and plan ahead. The ability to “listen in” on
communications directed at others that have a bearing on achievement of your own goals and to
recognize when information in your possession is of relevance to others and broadcast it, were
found to be important contributors to efficient management of track use (cf., the use of voice
loops technology in space shuttle mission control, Patterson et al., 2001).
Dispatchers routinely “listen for” information on the radio channel that is not directly
addressed to them but provides important clues to potential delays, problems or need for
assistance. As one dispatcher put it, “after a while you kind of fine tune your ear to pick up
6
certain key things.” Examples include:
Identifying when a train has left a station: A train conductor will generally tell the
locomotive engineer “OK out of New London.” By comparing the actual departure time to
the scheduled departure, a dispatcher can calculate train delays.
Identifying equipment problems: By overhearing conversation between a locomotive engineer
and the mechanical department, the dispatcher gets early notice of malfunctioning train
engines that will need to be replaced.
Listening for/heading off potential interactions and conflicts: Dispatchers listen for
commitments made by others that may impact activity in their territory. The ability to listen
ahead allows dispatchers to nip potential conflicts before they arise.
Listening for mistakes. An experienced train dispatcher will pick up key information that may
signal a misunderstanding, confusion, or error.
Implications for the Design of Data Link Technology
There are several implications for the design of data link technology from this study. First,
there was clear evidence from several observed incidents that the radio channel is now
overloaded and that there is a need to off-load some of the communication onto other media.
Data link technology provides a vehicle for taking information that is now communicated orally
and instead presenting it visually on a computer display. This has clear benefits for certain types
of information. For example having dispatchers read aloud and train crews repeat back
complicated movement authorization forms is time consuming and error prone. Transmitting the
information as a visual text or graphical display should reduce radio congestion and may reduce
the number of ‘read back’ errors and other errors of confusion and misunderstanding that
sometimes occur during verbal radio transmissions.
At the same time, the results of the observational study revealed the importance of the
“broadcast/party line” aspect of radio communication that provides a shared frame of reference
and allows dispatchers and others working on the railroad to anticipate situations and act
proactively. The study identified the need to preserve the ‘broadcast/party-line’ aspect of radio
communication when shifting to data link technology.
While data link technology is often implemented as a private communication channel where
only the specified receiver has access to the information transmitted, this is not an inherent
characteristic of the technology. It is possible to envision ‘broadcast’ versions of data link
technology where multiple individuals can access a transmitted message or view common
graphical displays regarding real time status of track and train information.
In order to explore this hypothesis under more controlled conditions, a follow-on laboratory
study was conducted. Malsch (1999) implemented two data link systems: a directed system with
no broadcasting capacity and a broadcast system. The systems were compared for their
effectiveness in a simulated railroad dispatching task with scenario elements abstracted from the
observed incidents. While both versions of data link resulted in more efficient communication as
compared to radio transmission, the broadcast version of data link produced better dispatcher
performance than the directed data link system on several measures such as train safety.
In summary, one of the most significant contributions of the study was that it revealed the
important role that the broadcast/’party-line’ feature of the radio communication media played in
facilitating safe and efficient dispatch operation in the current environment. Observed
illustrative incidents suggested that changing the design of the new data link technology in order
7
to preserve this ‘broadcast’ aspect of dispatcher communication would improve performance,
which was then confirmed in a follow-on controlled laboratory study.
STUDY 2: MAKING THE INTRODUCTION OF NEW TECHNOLOGY SAFER
The first study illustrated the use of an observational study to improve the design of a new
technology prior to implementation. Observational studies can also be used to reduce unintended
effects on performance from the introduction of new technology into a field of practice by
identifying training and operational changes that should accompany the implementation. The
next study illustrates how observation of operators in a high-fidelity simulator was used to
identify new training and operational needs prior to the implementation of advanced human-
system interfaces (HSI) in a nuclear power plant (Roth & O’Hara, 1999).
Introduction of new technology inevitably changes the nature of cognitive and collaborative
work. Some of these changes are explicitly engineered with the goal of improving performance.
However, there can also be unanticipated effects. It is easy to find examples where the
introduction of new systems have had unanticipated negative effects, creating new burdens for
practitioners, often at the busiest or most critical times (Roth, Malin, and Schreckenghost, 1997;
Woods, Johannesen, Cook and Sarter, 1994).
Woods and his colleagues (1998; Potter, Roth, Woods and Elm, 2000) have argued that new
support technologies should be regarded as hypotheses about what constitutes effective support,
and how technological change is expected to shape cognition and collaboration in the
“envisioned world” that contains the new technology (Dekker and Woods, 1999). Observational
studies provide a powerful tool for exploring the envisioned world both to evaluate the validity
of designer assumptions, and to drive further discovery and innovation. In this study, advanced
human-system interfaces (HSIs), including a computer-based procedure system, an advanced
alarm system, and a graphic-based plant information display system, were in the final phases
prior to implementation in a conventional nuclear power plant control room. Operators were
undergoing training on the use of the new interfaces on a high-fidelity full-scope simulator,
which provided an opportunity to observe the use of the technology by experienced operators
while handling plant disturbances and interview the operators immediately following the
simulation.
The guiding questions for this study were:
1) What aspects of the new HSIs were clear improvements over traditional control boards?
2) Were there any new unanticipated challenges or issues that emerged with the introduction
of the new HSIs?
The cognitive engineering literature on teamwork, the importance of shared representations
for supporting communication and coordination among team members, and the potential for new
technologies to create private ‘keyholes’ that can disrupt individual and team situation awareness
are examples of conceptual frameworks that were relevant and served to guide observations and
inquiries.
Approach
Five professional operating crews were observed and interviewed during a week of training
in a full scope, dynamic plant simulator. Each crew was unobtrusively observed during four
simulated emergency scenarios by two observers placed in an observation deck (instructor's
8
area.)
At the end of the two days of observation, the operators were interviewed in crews. The
primary purpose of the interviews was to obtain the operators’ perspective on how they used the
new HSI systems and how the new systems affected their performance as individuals and as a
team. Questions probed the perceived impact of the new systems on operator workload, situation
awareness, distribution of tasks and responsibilities among team members, and communication
and coordination among the team members.
Controlling a nuclear power plant involves dynamic, real-time communication and
coordination among individuals with dedicated roles and responsibilities. A control room crew
is typically made up of 3 individuals: a shift supervisor and two board operators, although others
augment the crew during emergencies. When there is an emergency that causes the plant to shut
down (i.e., a plant trip) in the current environment, the shift supervisor reads aloud paper-based
procedures, called Emergency Operating Procedures (EOP), that guide the crew step-by-step
through the emergency response. The board operators’ job is to read plant parameter values from
the board for the shift supervisor and take control actions as directed by the procedures that the
shift supervisor reads aloud. With the new HSI design, the parameters are automatically
provided to the shift supervisor as part of the computer-based procedure system.
Findings about Individual and Team Situation Awareness
We identified several aspects of the new HSIs that gave clear improvements, as well as had
unanticipated impacts on individual and team situation awareness. One of the most interesting
findings of the study was the impact of the HSI systems on the structure and dynamics of the
crew. The introduction of the new HSI affected the scope of responsibility of the different crew
members, the communication pattern among crew members, and the situation awareness of the
different crew members.
The new HSIs removed the need for detailed communication between the shift supervisor
and the board operator because the computer based procedure automatically provided the shift
supervisor with the plant parameter data required for him or her to work through the procedures.
The shift supervisor and board operators were able to work more in parallel. The shift supervisor
concentrated on working through the procedures and the board operators concentrated on
monitoring the advanced alarm system, graphics display, and control board HSIs. As a result, the
shift supervisor and the board operators individually reported improved situation awareness and
greater confidence in the accuracy and speed of their performance within their own locus of
responsibility.
There was an unanticipated effect, however. Operators reported that more conscious effort
was required to maintain awareness of each other's situation assessment and activities than with
the older hard-wired control board technology. While the computerized procedure reduced the
shift supervisor's overall workload, it also introduced a new demand -- the need to keep the crew
informed of his or her assessment of the situation and the status and direction of the procedural
path as he worked through the procedure. Shift supervisors reported a need to consciously
remember to inform the crew of their status through the procedure and to consciously formulate
what to communicate. The new communication requirement is a substantial cognitive task that
appeared to improve with training and experience.
Findings on the Ability To Monitor Effectiveness Of Procedures
9
Another question of interest was the impact of the new HSIs on the ability of crews to
monitor the effectiveness of the procedures in handling emergency scenarios. This included the
ability of the crews to detect and respond to cases where the actions specified in the procedures
were not fully appropriate to the specific situation. Several studies examining both actual and
simulated incidents have shown that conditions sometimes arise where response guidance in the
procedures are not fully appropriate to the situation (Kauffman, Lanik, Trager & Spence, 1992;
Roth, Mumaw & Lewis, 1994). In those cases, the ability of the crews to recognize that the
actions specified in the procedures are not fully appropriate to the specific plant conditions and to
take corrective action are important cognitive activities. As a consequence, one of the points of
focus in the present study was on how the computer-based procedures affected the operators’
ability to monitor the effectiveness of the procedures, and detect and respond to situations where
the actions specified by a procedural step were not fully appropriate to the situation.
In the study, three instances arose where the computer-based procedure provided misleading
information or directed the operators down the wrong procedural path. These instances
constitute an ‘existence proof’ of the fact that situations can arise where the procedural path taken
is not appropriate to the situation.
Given that situations can arise where the decision aid is off-track, important questions are:
(1) Can operators detect when the decision aid is off track? (2) Are they able to redirect the
decision aid and get back on track? In all three cases observed in the study, the operators were
able to correctly detect that the computer-based procedure direction was inappropriate to the
situation and overrode it. The examples illustrated important positive features of the computer-
based procedure, and raised questions about the conditions that are necessary to foster the ability
of crews to detect that a computer-based procedure is off-track and redirect it.
Implications for Training with the Introduction of the HSIs
The study suggested ways to make the introduction of the new HSIs safer through training
and operational changes. First, the new demand of supporting team situation awareness given
the elimination of “low level” communication about parameter values between the board
operator and shift supervisor can be addressed by explicit training and changes to communication
protocols to include periodic updates from the shift supervisor to the team about his or her
assessment of the situation and the location in a procedure.
Second, the three observed instances where the computer-based procedure was not
appropriate constituted an existence proof that instances where the computer-based procedure is
off-track can occur, and consequently that the task of detecting and redirecting the computer-
based procedure needs to be supported. The findings suggest the importance of having (1)
multiple diverse sources of information available to operators in the control room, and (2)
effective communication among the operators in order to detect and correct cases where the
computer-based procedure is off-track.
The ability of the operators to recognize that the actions specified were inappropriate seemed
to depend on three factors that have implications for training and operational changes:
1. accurate understanding of current plant state,
2. solid knowledge of the goals and assumptions of the procedures and the consequences
of the actions indicated by the procedure, and
3. strong communication between the shift supervisor and the board operators that
allowed the board operators to keep track of the procedural path that the shift
10
supervisor was following.
While the study provided some suggestive evidence of the kinds of factors that contribute to
the ability of crews to detect if a computer-based procedure was off-track, clearly more research
is required to fully address this issue. First, only three instances were observed and analyzed, and
these three instances might not be a representative sampling of the ways in which the computer-
based procedure could be misleading. Second, the observation that the control room crew easily
detected that the computer-based procedure was inappropriate for the situation may not
generalize to other individuals, teams, or situations, particularly since only one instance of each
situation was observed so there was no way to measure response variability. Further research is
needed to generate detailed recommendations for change and to verify that the recommendations
would have the desired effects on performance.
In summary, this study illustrates three important roles of observational studies
1. uncovering new cognitive and collaborative demands that were previously unanticipated
and could be addressed with training before the implementation of a system in an actual,
high-consequence work setting;
2. documenting illustrative cases that provide an ‘existence proof’ that certain situations can
arise that need to be explicitly considered by system designers, trainers, evaluators, and
managers; and
3. providing suggestive evidence that inform hypotheses for improving performance by
changes to training and operational procedures that can then be explored under more
controlled conditions.
DISCUSSION
In this chapter, two recent studies were used to illustrate the ways in which observational
studies can contribute to the growth of knowledge on human decision-making in complex
domains. In the first study, an important function of the current communication technology in
railroad dispatching was uncovered that had significant implications for the design of a new data
link digital communication technology. This function was “hidden” in the sense that it was an
adaptation that was not officially supported by the current technology and unlikely to have been
reported by the operators to be important. In the second study, a new demand for shift
supervisors to explicitly communicate situation assessments to a team using new advanced
displays in a nuclear power plant control room was uncovered. Because the observations were
conducted in a high-fidelity simulator prior to implementation, this new demand could be
included in training and operational changes that could be implemented at the same time as the
new system, therefore making the transition period safer. In addition, three instances where the
computer-based procedure was inappropriate to the situation were uncovered and documented.
They provided an existence proof that the situations could arise, and therefore that provisions to
support these situations and other similar situations needed to be made.
There are two phases that are important to the advancement of science. One is the
controlled experiment phase that is used to confirm a hypothesis by controlling for, and thus
eliminating, all other possible explanations for a given phenomenon. This controlled experiment
phase is generally associated with the concept of “Science”. But there is also another element of
the scientific process that is less widely discussed and that is the discovery phase. This is the
phase during which fruitful conjectures are generated that can then be tested under more
11
controlled conditions
Naturalistic observation studies are one of the tools that support this discovery phase of the
scientific process by increasing the empirical grounding of hypotheses about how tools will affect
work in complex settings. They serve to draw attention to significant phenomena and
relationships that might otherwise have been missed, and which can then be further explored in
more controlled investigations.
REFERENCES
Dekker S and Woods DD (1999). Extracting Data from the Future: Assessment and Certification
of Envisioned Systems. In S. Dekker and E. Hollnagel (Eds.), Coping with Computers in the
Cockpit. Ashgate, pp. 7-27.
De Keyser, V. (1990). Why field studies? In M. Helander, (Eds). Human Factors in Design for
Manufacturability and Process Planning, pp. 305-316. Geneva: International Ergonomics
Association.
Heath, C. and Luff, P. (2000). Technology in Action. Cambrdige, UK: Cambridge University
Press.
Hollnagel, E., Pederson, O., & Rasmussen, J. (1981). Notes on human performance analysis.
(Technical Report Riso-M-2285). Riso National Laboratory.
Kauffman, J.V., Lanik, G.F., Trager, A. and Spence, R.A. (1992). Operating Experience
Feedback Report
Human Performance in Operating Events. (NUREG-1275),
Washington, D.C.: Office for Analysis and Evaluation of Operational Data, U.S. Nuclear
Regulatory Commission.
Lipshitz, R. (2002). There is more to seeing than meets the eyeball: The art and science of
observation.
Mackay, W. (1999). Is Paper Safer? The Role of Paper Flight Strips in Air Traffic Control.
ACM Transactions on Computer-Human Interaction, Vol 6, No. 4, pp 311-340.
Malsch, N. F. (1999). Design and Testing of a Railroad Dispatching Simulator using Data-Link
Technology. Masters Thesis, Department of Aeronautics and Astronautics, Massachusetts
Institute of Technology.
Mumaw, R. J., Roth, E. M., Vicente, K. J. & Burns, C. M. (2000). There is more to monitoring a
nuclear power plant than meets the eye. Human Factors, vol 42, # 1, 36-55.
Nardi, B. A. (1997). The use of ethnographic methods in design and evaluation. In M. Helander,
T. K. Landauer & P. Prabhu, (Eds.) Handbook of Human-Computer Interaction (2nd edn.)
Amsterdam: North-Holland.
Patterson, E.S., Watts-Perotti, J., and Woods, D.D. (1999). Voice loops as coordination aids in
space shuttle mission control. Computer Supported Cooperative Work: The Journal of
Collaborative Computing, 8(4), 353-371.
Patterson, E.S., and Woods, D.D. (2001). Shift changes, updates, and the on-call model in space
shuttle mission control. Computer Supported Cooperative Work: The Journal of
Collaborative Computing, 10(3-4), 317-346.
12
Potter, S. S., Roth, E. M., Woods, D. D. & Elm, W. (2000). Bootstrapping multiple converging
cognitive task analysis techniques for system design. In J. M. Schraagen, S. F. Chipman &
V. L. Shalin (Eds.) Cognitive Task Analysis (pp. 317-340). Mahwah, NJ: Lawrence Erlbaum
Associates, Inc.
Roth, E. M., Malin, J. T. , & Schreckenghost, D. L. (1997). Paradigms for Intelligent Interface
Design. In M. Helander, T. Landauer & P. Prabhu (Eds.) Handbook of Human-Computer
Interaction (2nd edition), Amsterdam: North-Holland. (pp. 1177-1201).
Roth, E. M., Malsch, N. and Multer, J. (2001). Understanding how train dispatchers manage and
control trains: Results of a cognitive task analysis. Washington, C. C.: U. S. Department of
Transportation/Federal Railroad Administration. (DOT/FRA/ORD-01/02) Available online
at: http://www.fra.dot.gov/pdf/cta.pdf
Roth, E. M., Malsch, N., Multer, J., & Coplen, M. (1999). Understanding how train dispatchers
manage and control trains: A cognitive task analysis of a distributed planning task. . In
Proceedings of the Human Factors and Ergonomics Society 43rd Annual Meeting (pp. 218-
222). Santa Monica, CA: Human Factors and Ergonomics Society.
Roth, E.M., Mumaw, R.J., and Lewis, P.M., (1994). An Empirical Investigation of Operator
Performance in Cognitively Demanding Simulated Emergencies. (NUREG/CR-6208),
Washington, D.C.: U.S. Nuclear Regulatory Commission.
Roth, E. M. & O’Hara, J. (1999). Exploring the impact of advanced alarms, displays, and
computerized procedures on teams. In Proceedings of the Human Factors and Ergonomics
Society 43rd Annual Meeting (pp.158-162). Santa Monica, CA: Human Factors and
Ergonomics Society.
Vicente, K. J., Roth, E. M., Mumaw, R. J. (2001). How do operators monitor a complex,
dynamic work domain? The impact of control room technology. International Journal of
Human Computer Studies, 54, 831-856. Available online at: http://www.idealibrary.com
Woods, D. D. (1995). Process-tracing methods for the study of cognition outside the
experimental psychology laboratory. In G. A. Klein, J. Orasanu, R. Calderwood & C. E.
Zsambok (Eds.) Decision Making in Action: Models and Methods. Norwood, NJ: Ablex
Publishing Corporation.
Woods, D. D. (1998). Designs are hypotheses about how artifacts shape cognition and
collaboration. Ergonomics, 41, 168—173.
Woods, D. D., Johannesen, L. J., Cook, R. I., and Sarter, N. B. (1994). Behind Human Error:
Cognitive Systems, Computers, and Hindsight. Crew Systems Ergonomic Information and
Analysis Center (CSERIAC), Dayton, OH (State of the Art Report).
... The many adaptations and variants of TAM and the discussions about its relevance in health care highlight the importance of carefully considering what "Usefulness" and "Ease of Use" mean in each specific case. However, the model's construct definitions can support qualitative data collection, analyses, and the interpretation of findings [42,43]. ...
... The quality of our findings is grounded in the qualitative data, rather than in statistical inference [58]. This study represents "the scientific discovery phase" [42], where empirical findings from a complex setting can ground hypotheses about behavior and design. In this sense, items with low agreement or ambiguous findings such as the seemingly contradictory beliefs about patient safety are valuable indications about how similar studies can be refined. ...
Article
Full-text available
Background Telemedicine innovations are rarely adopted into routine health care, the reasons for which are not well understood. Teleguidance, a promising service for remote surgical guidance during endoscopic retrograde cholangiopancreatography (ERCP) was due to be scaled up, but there were concerns that user attitudes might influence adoption. Objective Our objective was to gain a deeper understanding of ERCP practitioners’ attitudes toward teleguidance. These findings could inform the implementation process and future evaluations. Methods We conducted semistructured interviews with ERCP staff about challenges during work and beliefs about teleguidance. Theoretical constructs from the technology acceptance model (TAM) guided the thematic analysis. Our findings became input to a 16-item questionnaire, investigating surgeons’ beliefs about teleguidance’s contribution to performance and factors that might interact with implementation. Results Results from 20 interviews with ERCP staff from 5 hospitals were used to adapt a TAM questionnaire, exchanging the standard “Ease of Use” items for “Compatibility and Implementation Climate.” In total, 23 ERCP specialists from 15 ERCP clinics responded to the questionnaire: 9 novices (<500 ERCP procedures) and 14 experts (>500 ERCP procedures). The average agreement ratings for usefulness items were 64% (~9/14) among experts and 75% (~7/9) among novices. The average agreement ratings for compatibility items were somewhat lower (experts 64% [~9/14], novices 69% [~6/9]). The averages have been calculated from the sum of several items and therefore, they only approximate the actual values. While 11 of the 14 experts (79%) and 8 of the 9 novices (89%) agreed that teleguidance could improve overall quality and patient safety during ERCP procedures, only 8 of the 14 experts (57%) and 6 of the 9 novices (67%) agreed that teleguidance would not create new patient safety risks. Only 5 of the 14 experts (36%) and 3 of the 9 novices (33%) were convinced that video and image transmission would function well. Similarly, only 6 of the 14 experts (43%) and 6 of the 9 novices (67%) agreed that administration would work smoothly. There were no statistically significant differences between the experts and novices on any of the 16 items (P<.05). Conclusions Both novices and experts in ERCP procedures had concerns that teleguidance might disrupt existing work practices. However, novices were generally more positive toward teleguidance than experts, especially with regard to the possibility of developing technical skills and work practices. While newly trained specialists were the main target for teleguidance, the experts were also intended users. As experts are more likely to be key decision makers, their attitudes may have a greater relative impact on adoption. We present suggestions to address these concerns. We conclude that using the TAM as a conceptual framework can support user-centered inquiry into telemedicine design and implementation by connecting qualitative findings to well-known analytical themes.
... As prior work has argued, immersing researchers in the actual work environment of nurses can yield valuable insights into their daily tasks, interactions, and challenges [19]. Observations were conducted in the mornings, aligning with what the participants regarded as peak activity times for RPM interactions. ...
Preprint
Full-text available
Remote patient monitoring (RPM) involves the remote collection and transmission of patient health data, serving as a notable application of data-driven healthcare. This technology facilitates clinical monitoring and decision-making, offering benefits like reduced healthcare costs and improved patient outcomes. However, RPM also introduces challenges common to data-driven healthcare, such as additional data work that can disrupt clinician's workflow. This study explores the daily practices, collaboration mechanisms, and sensemaking processes of nurses in RPM through field observations and interviews with six stakeholders. Preliminary results indicate that RPM's scale-up pushes clinicians toward asynchronous collaboration. Data sensemaking is crucial for this type of collaboration, but existing technologies often create friction rather than support. This work provides empirical insights into clinical workflow in nursing practice, especially RPM. We suggest recognizing data sensemaking as a distinct nursing practice within data work and recommend further investigation into its role in the workflow of nurses in RPM.
... Research group meetings between shadowing observations provided focus for subsequent data collection and opportunity for the research team to discuss KHs observations and potential observer bias. The ethnographic design with several iterations of data collection and analysis did enable the research team to let the conceptual frameworks of CSE to guide observations, and to continuously visualise observed dependencies within the multi-layered organisation (Roth and Patterson 2005). ...
Article
Full-text available
Hospitals work to provide quality, safety, and availability to patients with a wide variety of care needs, which makes efficient prioritization and resource utilization essential. Anticipation of each patients' trajectory, while monitoring available resources across the hospital, are major challenges for patient flow management. This study focuses on how hospital patient flow management is realized in situ with the help of concepts from cognitive systems engineering. Five semi-structured interviews with high level managers and shadowing observations of seven full work-shifts with management teams were conducted to explore how patient flow is coordinated and communicated across the hospital. The data has been analysed using qualitative content analysis. The results describe patient flow management using an adapted Extended Control Model (ECOM) and reveal how authority and information might be better placed closer to clinical work for increased efficiency of patient flow.
... Data analysis for the patients' responses to the openended survey items followed an established process of upward abstraction of qualitative data (Roth & Patterson, 2005;Xiao & Vicente, 2000) in which the data were represented at a higher level of abstraction so that the data can be integrated across participants, revealing recurrent patterns related to the study objectives. An inductive coding strategy was used (i.e., allowing codes to emerge from the data rather than using a pre-determined coding scheme) by two team members (JS and JH) to independently code the first 50 responses for each protocol and develop a coding dictionary. ...
Article
Full-text available
Automated text messaging interventions can effectively improve self-care and were used to support the U.S. Veterans Health Administration’s (VHA) public health outreach during the COVID pandemic. Currently, significant gaps exist in knowledge about VHA patients’ texting protocol preferences that may impact user receptivity, engagement, and effectiveness. This study qualitatively evaluated patient suggestions to improve two VHA Covid-related texting interventions and preferences for future text message protocols. We reviewed cross-sectional type-written survey responses from patients receiving either the “Coronavirus Precautions” or the “Coping During COVID” multi-week text protocols. Two team members independently and inductively coded all responses allowing for an upward abstraction of qualitative data. Nine hundred five patients (72.8% male) responded to the open-response item questions targeted by this research. An item that sought feedback to improve protocol acceptability generated thirteen distinct descriptive categories (inter-rater reliability 83.5%). Codable feedback showed, for example, that patients desired to manipulate message frequency and to have a more sophisticated interaction with messages. Patients’ suggestions for future automated text messaging protocols yielded nine distinct topic areas. Patients offered suggestions that may impact receptivity and engagement of future automated text message protocols, particularly as they relate to outreach during a public health crisis. In addition, patients offered specific topics they would like to see in future text message protocols. We discuss how the findings can be used to increase engagement in current and post-pandemic public health interventions.
... The original coding scheme from Saleem et al. (2020) was developed using an inductive coding approach (Roth & Patterson, 2005;Xiao & Vicente, 2000), allowing codes to emerge from the data based on recurrent findings across participants. Using this original coding scheme, one team member coded an initial set of 50 responses. ...
Article
Full-text available
Coping with stressors related to the coronavirus disease (COVID) pandemic has caused major mental health challenges. Text message interventions are identified as helpful for promoting health behavior self-management. Drawing from cognitive-behavioral theory (CBT), U.S. Veterans Health Administration staff developed a 20-week automated text messaging protocol called “Coping During COVID” to support veterans’ self-care during the pandemic. This project evaluated attitudes about and perceived helpfulness of the protocol among 651 veterans. A cross-sectional evaluation quantitatively assessed COVID-related stressors as well as reported use, acceptability, attitudes, and perceived helpfulness of the protocol via a self-administered online questionnaire. Open-ended questions assessed perceived helpfulness/unhelpfulness of the protocol. Of the 651 veterans (22% of those enrolled in the protocol) who responded to the survey, 73.1% were male and 88.5% were 50 years or over. Ninety percent found the protocol messages helpful and about half endorsed various additional benefits, including feeling better, being more educated about coping behaviors, and being better able to focus on positive thoughts. Qualitative feedback was overwhelmingly positive. For example, veterans stated that the protocol “was like having a personal coach giving hints and tips to cope with the boredom every day,” that it “gave me reminders of skills I was not using. It helped me focus on the positives,” and brought relief from “many hopeless and sad thoughts … the messages from Annie have been a Godsend to me.” Overall results suggested that the Coping During COVID text messaging protocol successfully supported the majority of respondents’ self-care efforts during the COVID pandemic.
... In a paper on decision-making in technically complex domains, two scholars of the North American cognitive engineering tradition, Emilie Roth and Emily Patterson, argue that 'naturalistic observation studies' are essential in that they support the 'discovery phase' of scientific research: they 'serve to draw attention to significant phenomena and suggest new ideas whose validity and generality can then be evaluated through additional studies' (Roth and Patterson 2005). This conception of the role of field studies in technological research is of course rather similar to the conception of ethnography in CSCW as outlined by, for instance, Hughes et al. (1994) and Randall et al. (2007). ...
... Porthin analyzed and summarized a large number of literatures on the influence of traditional context and digital context on operators, and found that different studies have different results, and some results are even contrary (Porthin et al., 2019). For example, Roth (Roth and Patterson, 2005) and Lin (Lin et al., 2016) found that the digital human-machine interface can improve the situational awareness and performance of the operators; while Kaarstad (Kaarstad et al., 2010) and Zou (Zou et al., 2017) found that the digital human-machine interface can make it more difficult for operators to obtain an overall understanding of the state of the power plants and easily lose situational awareness. The digitalization does bring effects to operators, which is different from the traditional NPPs. ...
Article
The performance shaping factors (PSFs) of the standardized plant analysis of risk-human reliability analysis (SPAR-H) method are unclearly defined, which contributes to the uncertainty of human reliability analysis (HRA) in nuclear power plants (NPPs). This work proposes an expert-based modification approach for redefining the PSFs based on four criteria in terms of less overlap, hierarchy, flexibility, and digitalization. For demonstration, the proposed approach is used to assign PSFs to three specific human failure events in NPPs. Three tests (Kendall's W Test, Jonckheere-Terpstra Test, and Paired Samples Test) are applied to analyze the assignments. Compared to the PSF assignment of SPAR-H, the results show that the redefined PSFs meet the four criteria and reduce the overestimation of human error probabilities (HEPs).
Chapter
This chapter describes the discipline of human factors engineering and how it can be specifically applied to the study and improvement of clinical workflow. Human factors engineering is a well-established scientific discipline that studies the functional capabilities and limitations of humans and methods to integrate these findings into the design and optimization of systems, processes and technology. The chapter introduces core concepts and methods from the discipline of human factors engineering and describes how they can be applied to the study and improvement of clinical workflow. Applications include situations where there is a need to understand why performance problems or errors are occurring and what can be done to mitigate them; cases where new Health Information Technology (health IT) is being developed and there is a need to understand work as currently done to insure that the new system will meet the needs of users and effectively support workflow; as well as cases where a new process is introduced and there is a need monitor and manage its impact on user workflow, performance, and satisfaction. The human factors methods presented can be used by a variety of organizations and stake-holders (e.g., technology vendors; clinical organizations, quality and safety departments, and individual researchers) and tailored to the scope, size, and budget of the project. The chapter also covers new developments in how machine learning and artificial intelligence (AI) can play a role, but still needs further study. The chapter will cover considerations in using these advanced technologies, including potential for both improved analytics but also the introduction of new safety concerns, as well as technical and cost considerations when leveraging new methods.
Article
Provider burnout has reached epidemic levels, especially with primary care-oriented specialties such as Family Medicine. Guided by a sociotechnical systems perspective, we investigated contributing burnout factors that relate to the electronic health record (EHR) and clinical workflow in an academic healthcare institution. We conducted semi-structured interviews with 10 family medicine and geriatrics providers and administered EHR usability and workflow integration surveys. Findings are organized around recurrent, overarching themes: (1) Clinic Workflow, (2) Documentation, (3) EHR Workflow and Usability, (4) Patient Complexity, (5) Staffing, and (6) Technical Issues. The most consistent finding across all provider interviews was poor EHR usability as a contributing factor to burnout; especially the number of clicks needed to complete EHR tasks. This finding is supported by low usability and workflow integration survey ratings. Using a sociotechnical systems framework, we demonstrate social, technological, and environmental contributors to burnout and discuss potential interventions to mitigate these contributing factors.
Article
Full-text available
The US Department of Veterans Affairs (VA) is using an automated short message service application named "Annie" as part of its coronavirus disease 2019 (COVID-19) response with a protocol for coronavirus precautions , which can help the veteran monitor symptoms and can advise the veteran when to contact his or her VA care team or a nurse triage line. We surveyed 1134 veterans on their use of the Annie application and coronavi-rus precautions protocol. Survey results support what is likely a substantial resource savings for the VA, as well as non-VA community healthcare. Moreover, the majority of veterans reported at least 1 positive sentiment (felt more connected to VA, confident, or educated and/or felt less anxious) by receiving the protocol messages. The findings from this study have implications for other healthcare systems to help manage a patient population during the coronavirus pandemic.
Article
Full-text available
Potter, S. S., Roth, E. M., Woods, D. D. and Elm, W. (2000). Bootstrapping Multiple Converging Cognitive Task Analysis Techniques for System Design. In Schraagen, J.M.C., Chipman, S.F., & Shalin, V.L. (Eds.), Cognitive Task Analysis. Mahwah, NJ: Lawrence Erlbaum Associates, pp. 317-340.
Article
Full-text available
Washington, D.C. A Cognitive Task Analysis was conducted to examine how experienced railroad dispatchers manage track use. The results reveal the cognitive complexities faced by dispatchers and the cognitive and collaborative strategies developed in response to those demands, including strategies to support anticipation and planning, and proactive strategies to exploit windows of opportunity to satisfy the multiple demands on track use. In many cases these strategies depend on communication and cooperation among individuals distributed across time and space (i.e., multiple dispatchers, locomotive engineers, maintenance of way personnel). The ability to "listen in" on communications directed at others that have a bearing on achievement of your own goals and to recognize when information in your possession is of relevance to others, are important contributors to safe and efficient track use. The results reinforce findings from other domains (e.g., space shuttle mission control, air traffic control) regarding the role of a shared communication channel in supporting anticipation and contingency planning. Implication for the introduction of advanced "data-link" communication technologies, as well as for dispatcher training are discussed.
Article
There has been a transition in many supervisory control domains from continuous monitoring to minimizing staffing until a problem arises. The key to making this “on-call” model effective is to understand how to bring practitioners up to speed quickly when they are called in. A field study was conducted to investigate what it means to update a supervisory controller on the status of a continuous, anomaly-driven process in a complex, distributed environment. Sixteen shift changes, or handovers, were observed during an anomalous space shuttle mission. Handover updates included descriptions of events that had occurred, ongoing activities, results of data analyses, and changes to mission plans. The controllers engaged in intense, interactive briefings that highlighted what the incoming controller needed to review more deeply following the update. Interrogation strategies were employed by the incoming controllers. Implications for organizational investments and the design of tools to support updates are discussed.
Article
New support technologies embody hypotheses about what constitutes effective support, and how technological change is expected to shape cognition and collaboration. Introduction of these technologies into a field of practice provides an opportunity to test and revise our understanding. An illustrative case is presented that examined the impact of introducing advanced human-system interfaces (HSIs), including a computer-based procedure system, an advanced alarm system, and a graphic display system, into a conventional power plant control room. Crews were observed using the HSIs to handle simulated plant disturbances in a full-scope simulator. The HSIs generally provided positive support and reduced workload as intended. However, unanticipated impacts were also identified. Of particular note was the effect on team structure and communication. The computerized systems altered the distribution of information across crew members and communication patterns, affecting the situation awareness of individual crew members and the crew as a whole. While in a traditional control room, the open environment, and explicit communication requirements foster shared situation awareness, maintaining shared situation awareness in the computerized environment required active work on the part of crew members. The results point to requirements for effectivecollaboration and help define future research direction.
Article
The term “intelligent interface” has grown to be an umbrella term that covers a wide and diverse range of topics including dialog understanding, user modeling, adaptive interfaces, cooperative person-machine approaches to problem-solving and decision making, and use of machine intelligence to create more effective explanations and visualizations. This chapter uses the term “intelligent interface” to refer to both the design of user interfaces for intelligent systems and the design of user interfaces that utilize knowledge-based approaches. The chapter examines three broad paradigms for development of intelligent interfaces: intelligent interfaces as cognitive tools that can be utilized by practitioners in solving their problems; intelligent interfaces as members of cooperative person-machine systems that jointly work on problems and share task responsibility; and intelligent interfaces as representational aids that dynamically structure the presentation of information to make key information perceptually salient. The chapter begins with a review of some of the limitations associated with the stand-alone machine problem-solver paradigm that stimulated exploration of alternative paradigms for deployment of machine intelligence. This is followed by a description of each of the three paradigms for intelligent interface design. In each case, examples of systems are presented representing that paradigm and some of the key design principles that derive from that paradigm.
Article
The point of ethnography is to find out not how people respond to a constructed situation in which narrowly pinpointed variables are studied, as in experimental psychology, but to learn how people actually work and play. The chief ethnographic methods are interviews, observations, and participant-observation. Participant-observation involves spending a great deal of time with and participating in the everyday lives of the natives. Participant-observation gives a good feel for the rhythms and challenges of the lives of those that the researcher studies. Participant-observation helps the researcher to see the world through native eyes. While technology studies usually do not require actually living with the natives, the method is still useful when spending lengthy periods of time with informants. One of the greatest strengths of ethnography is its flexible research design. The study takes shape as the work proceeds. People are such surprising creatures that it is impossible to know what may be of interest in a research setting before the work is done.
Article
This report describes the results of a Nuclear Regulatory Commission (NRC) program begun in 1990 to conduct onsite, indepth studies of human performance that affected reactor safety during selected power reactor events. The purpose of the program is to identify the factors that have contributed to good operator performance during events, as well as the factors that hindered performance, and to feed this information back to industry. Under the human performance study program, six onsite studies were performed in 1990, seven in 1991, and three in 1992. Each onsite study was conducted by a multi-disciplinary team, lead by an NRC staff member, with additional NRC and Idaho Team National Engineering Laboratory personnel. The events studied include a wide variety of accident scenarios, including: stuck open safety-relief valve, reactor trip with safety injection, reactor scram due to positive reactivity insertion, reactor scram due to control rod withdrawal, pressurizer spray valve failure, partial loss of instrument air in containment, turbine building pipe rupture, loss of shut-down cooling, excess steam demand event, main steam isolation, loss of electrohydraulic fluid, and reactor water cleanup isolation defeated. This report provides information on control room staffing and organization, the ``dual-role`` shift technical advisor, use of shift resources during emergencies, operator control of engineered safety features, simulator training, crew teamwork during stressful situations, task awareness, use of procedures, the human-machine interface, and licensee followup on events. The information could be useful to licensee in efforts to upgrade existing programs to improve safety.
Article
This report documents the results of an empirical study of nuclear power plant operator performance in cognitively demanding simulated emergencies. During emergencies operators follow highly prescriptive written procedures. The objectives of the study were to understand and document what role higher-level cognitive activities such as diagnosis, or more generally `situation assessment`, play in guiding operator performance, given that operators utilize procedures in responding to the events. The study examined crew performance in variants of two emergencies: (1) an Interfacing System Loss of Coolant Accident and (2) a Loss of Heat Sink scenario. Data on operator performance were collected using training simulators at two plant sites. Up to 11 crews from each plant participated in each of two simulated emergencies for a total of 38 cases. Crew performance was videotaped and partial transcripts were produced and analyzed. The results revealed a number of instances where higher-level cognitive activities such as situation assessment and response planning enabled crews to handle aspects of the situation that were not fully addressed by the procedures. This report documents these cases and discusses their implications for the development and evaluation of training and control room aids, as well as for human reliability analyses.