Book

Human Error:: Cause, Prediction, and Reduction

Authors:
... Partly based on Reason's and Rasmussen's taxonomies, Senders and Moray (1991) provided three taxonomies of human error as phenomenological taxonomies (phenotypes), cognitive mechanism taxonomies (genotypes), and taxonomies for biases or deep-rooted tendencies, which can be explained as "what happened," "how it happened," and "why it happened," respectively. ...
... Humans are hardly predictable in a general view, while specific human errors may be predictable for some given situations. In order to predict human errors, a detailed task analysis is necessary to recognize mismatches between demands from a task and the operator's capabilities to implement this task (Senders & Moray, 1991). Among a variety of task analysis techniques, two well-known and widely-used methods are Hierarchical Task Analysis (HTA) and Cognitive Task Analysis (CTA). ...
... Perhaps the best definition of Human Errors, for the purposes of this paper, is by Senders and Moray (1991): "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". [1] p 25. ...
... Perhaps the best definition of Human Errors, for the purposes of this paper, is by Senders and Moray (1991): "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". [1] p 25. We can see from the above definition that an error, in an organizational sense, can be an action or behavior or decision that is beyond the tolerances of the organizational system. ...
... To appear as wrong, the underlying mental model (in the sense of a knowledge base) is assumed to be fragmented or applied in a faulty way (Bauer et al. 2010). This application results in a good plan that is badly executed or a mistaken plan (Senders and Moray 1991). Regarding the cognitive execution level, a differentiation between slips and lapses and rule-and knowledgebased errors is formulated (Rasmussen 1987a). ...
... As the latter are especially open to deliberate training (Bauer 2008), we concentrate on these. Furthermore, slips and lapses do not qualify as errors, as they happen accidentally (Bauer and Mulder 2007;Harteis et al. 2008Harteis et al. , 2012Rasmussen 1987b;Rausch 2012;Reason 1987;Senders and Moray 1991;Weingardt 2004). Rule-based errors address the faulty use of if-then rules and other procedural aspects of a process (Weingardt 2004). ...
Article
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Intrapreneurship competence, as one of the main twenty-first century skills, has moved into focus, as it enables benefits for both organizations and individuals. To foster associated competencies and enable tailor-made instruction, teachers need knowledge not only about what their students can do but also about which errors are typically made within this domain. To identify such knowledge, we analyzed the results from a large-scale assessment (5436 responses). We then classified the errors found according to more overarching error categories and assigned them to the facets of a previously developed and validated intrapreneurship competence model to obtain a deeper understanding of which facets of intrapreneurship are not mastered and what the problems are. Additionally, we refer to more general error types in the domain of creative problem-solving to integrate our findings into the broader discussion. By formulating this error-related information as domain-specific negative knowledge, which refers to “how something is not” or “how something does not work”, respectively, we can use this information constructively when designing instructional means for future tailor-made approaches and individual guidance.
... Static electricity, friction, impact, and human errors are all potential hazards in chemical blending. Careless handling, impact loading, and inappropriate stacking and dragging are among the unsafe acts termed as "human errors" that lead to accidents [3]. The primary goal of occupational health and safety is to protect workers from work place accidents by providing appropriate risk mitigation measures [4]. ...
... The HFE's purpose is to reduce the possibility of human mistakes and accidents by ensuring that humans can accomplish assigned tasks as efficiently and effectively as possible. At the most fundamental level, human mistakes can be defined as any divergence from predicted human performance [3]. ...
... Hancock et al. (2019, p. 363) described the Clambake Conferences as "seminal foundations for the modern study of error in all its forms." Senders and Moray (1991) text, a product of the conferences, helped guide subsequent error research, articulating much of what is today widely accepted. "If every error has its own unique cause," they wrote, the practical designer of complex systems faces insuperable problems. ...
... A change to a systems-centered view of error causation, as Senders and Moray (1991) espoused, was not only timely, but logical as well, naturally following Fitts' research that had demonstrated a link between display design and error. No other suggested approach to error causation before or since could match that of system-centered causation for simplicity, generalizability, and applicability. ...
Article
Objective: I examine John Senders' work and discuss his influence on the study of error causation,error mitigation, and sociotechnical system safety. Background: John Senders' passing calls for an evaluation of the impact of his work. Method: I review literature and accident investigation findings to discuss themes in Senders' work and potential associations between that work and error causation and system safety. Results: Senders consistently emphasized empirical rigor and theoretical exploration in his research, with the desire to apply that work to enhance human performance. He has contributed to changing the way error has been viewed, and to developing and implementing programs and techniques to mitigate error. While a causal relationship between Senders' work and safety cannot be established, an association can be drawn between his research and efforts to mitigate error. Conclusion: Because of Senders' work, we have a better understanding of error causation and enhanced ways of mitigating system errors. However, new sources of error, involving advanced systems and operators' knowledge and understanding of their functionalities can, if not addressed, degrade system safety. Application: Modifications to advanced automation and operator training are suggested, and research to improve operator expertise in interacting with automated systems proposed.
... Human behavior generally varies to a certain degree, even under stable environmental conditions. Depending on the degree of variation, this unexpected behavior can sometimes be considered a mere error that should be avoided, but sometimes it is creative and can be valuable (Senders & Moray, 1991). However, if "creativity and error are opposite sides of the same coin (unplanned variation in performance), then eliminating error, if that were possible, might also inhibit creative problem-solving" (Senders & Moray, 1991, p. 9). ...
Thesis
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Our world is changing rapidly, and work follows suit. Considering the traditional division of work in physical and mental labor, it is primarily physical labor that has been systematically analyzed and optimized over the last century. This made it possible to break down many manual tasks into small entities that could eventually be automated. Advances in cognitive computing and artificial intelligence suggest that mental work might be next in line. In fact, some basic cognitive tasks have already been automated. A final frontier on the road towards ubiquitous automation, however, seems to be the generation of creative ideas. This suggests that the human capability to create will become increasingly important, especially in the workforce. The overarching theme of this thesis is creativity and its role in the modern workplace. The thesis identifies and contributes to two major research areas, namely creativity measurement and creativity amplification. In the area of creativity measurement, this thesis builds upon the current literature to develop and evaluate a new and innovative tool for objective creativity measurement, the Creativity Assessment via Novelty and Usefulness (CANU). The results of several experimental studies suggest that while the CANU does not eradicate all problems connected to creativity measurement, it does prove an easy-to-use, scalable, and comparable tool. In this way, this thesis highlights the shortcomings of current creativity measurement systems, especially for fundamental research. In the area of creativity amplification, the gaining momentum in the human computer interaction community, and the identification of creativity as paradigm have prompted the user centered development of three creativity support systems. The results of experimental exploration and evaluation in this project indicate that people who are inherently creative do not need (or want) support, whereas those who traditionally struggle with creative problem solving can benefit from inspirational stimuli. Overall, this thesis highlights the need for standardization in creativity measurement. It emphasizes the opportunity that creativity support can offer in terms of ergonomic optimization of system performance, and recognizes human factors/ergonomics as particularly suited discipline to tackle creativity measurement and amplification in a human-centered way.
... A piece of the puzzle is so-called human error. The fact that human errors have contributed to some of the most serious infrastructure and technological disasters, such as Three Mile Island in 1979 and Chernobyl in 1986, has been (Senders and Moray, 1991;Reason, 1990), and continues to be a major theme (e.g. Saeed, Bajwa and Bakwa, 2014). ...
... Human behavioral failures result in fatalities, heavy economic loss, and emotional distress (Senders and Moray, 2020). Given the grave implications of COVID-19, noncompliance with prevention guidelines may be regarded as a specific type of behavioral-failure. ...
Article
The mitigation of pandemics like that caused by the current COVID-19 virus is largely dependent on voluntary public adherence to government rules and regulations. Recent research has identified various individual covariates that account for some of the variance in compliance with COVID-19 behavioral guidelines. However, despite considerable research, our understanding of how and why these factors are related to adherence behavior is limited. Additionally, it is less clear whether disease-transmitting behaviors during a pandemic can be understood in terms of more general behavioral tendencies. The current research has examined the utility of a behavioral-failure lens in predicting adherence to COVID-19 guidelines and in illuminating mechanisms underlying the previously established relationship between Conscientiousness and adherence. In the two studies reported here, individual variations in the predisposition to behavioral failures predicted adherence to COVID-19 measures, and mediated the relationships between Conscientiousness and adherence. The Failure Proneness (FP) questionnaire predicted compliance with COVID-19 guidelines, while the Cognitive Failure Questionnaire (CFQ) did not. The results of hierarchical regressions showed that COVID-19 behavior was predicted only through the intentional factors (and mainly by Noncompliance-Violations). Hence, our data lend support to the notion that noncompliance with official COVID-19 prevention guidelines is driven mainly by intentional factors related to violation of norms and rules. The theoretical and practical implications of this finding are discussed.
... Results of eye-tracking studies show that human error causes most accidents. With respect to automobiles, this reflects the fact that driving virtually always consists of a series of complex behaviors, such that deviation from intention, other drivers' expectations, or desirability [24] may cause severe injury and even death. Similarly, human error in aviation is also critical; it can lead to catastrophic consequences that passengers have a slim chance of surviving. ...
Article
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In the last decade researchers have increasingly considered eye tracking of the operators of cars and airplanes as a means to address human error and evaluate operational effectiveness. This article presents a systematic survey of recently published papers about this approach in service to the question as to whether eye tracking can be used to address operational safety in marine operations. The surveyed papers are selected systematically and were categorized according to several defined characteristics. Eye tracking depends on defining operators’ areas of interest (AOIs) and measuring operators focus on them over time. We identified the method of defining AOIs as a key distinction between studies; the papers fell into four categories, depending on whether researchers relied on an expert, based it on the stimulus itself, or used an attention map or a clustering algorithm to define the AOIs they used. The article also summarizes and analyzes the design and procedure of the eye-tracking experiments in the papers. Based on the features of marine operation, instruction on AOI definition in different scenarios is extracted; guidelines on experimental design and procedure selection are provided. In the article’s conclusion we apply the results to a case study of a heavy-lifting operation to demonstrate the effectiveness of eye-tracking in marine operations.
... The incidents were classified based on a taxonomy derived from what researchers on human error would call the external mode of the error, that is, the overt practitioner actions that contributed to the incident described in terms of the domain itself. Examples of the external mode of the error in anesthesiology that were used in this study included circuit problems, syringe swap, etc. (for general discussions of the taxonomy of error taxonomies, see Rasmussen, 1982;Senders and Moray, 1991). Other studies (e.g., Williamson, et al., 1985) followed the Cooper work using a similar retrospective self report technique and similar taxonomies, again based on the external mode of the error. ...
Technical Report
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This report describes research conducted during 1989 and 1990 on the cognitive characteristics of a corpus of anesthesia critical incidents. The incidents were collected by monitoring and transcribing the regular quality assurance conferences in a large, university anesthesiology department. The 57 reports of incidents were analyzed by constructing protocols which traced the flow of attention and the knowledge activation sequence of the participants. Characteristics of the resulting protocols were used to divide the collection into five categories: acute incidents, going sour incidents, inevitable outcome incidents, airway incidents, and non-incident incidents. Of these, the acute and going sour categories represent distinct forms of incident evolution. The implications of this distinction are discussed in the report. Nearly all of the incidents involve human cognitive performance features. Cognition clearly plays a role in avoiding incidents but also in aborting and recovering from incidents in progress. Moreover, it is clear that subtle variations in cognitive function may playa crucial role in anesthetic disasters, of which incidents are taken to be prototypes. Review of the corpus reveals the different cognitive functions involved in anesthesia and anesthesia incidents. These cover a wide range including classic aspects of cognition, for example the direction of attention, and complex and poorly understood aspects such as situation awareness. The cognitive features include dealing with competing goals, dealing with competing indicators, the limitations of imperfect models, knowledge activation failures, the role of learned procedures and assumptions in reducing cognitive workload, failure to integrate multiple themes, organizational factors, and planning. These presence of these different cognitive features and cognitive failures in a single discipline is significant because it enhances and supports separate findings from other domains (e.g. nuclear power plant operation, commercial aviation) and also because it provides strong support for the contention that operators acting in these semantically complex, time pressured, high consequence domains face common problems and adopt similar strategies for dealing with them. The report demonstrates the way in which cognitive analysis of incidents can be accomplished in anesthesia and in other domains and suggests a system for categorizing the results obtained. It also raises questions about the adequacy of evaluations of risk and safety that do not explicitly account for the cognitive aspects of incidents and their evolution. In order to make real progress on safety in domains that depend critically on human operators it is necessary to examine and assess human cognitive performance, a process which requires large amounts of data and careful reconstruction. Such cognitive analysis is difficult. It requires substantial experience, skill, and effort and depends on acquiring and sifting through large quantities of data. This should not be suprising, since the domain itself is one characterized by experience, skill, effort, and large quantities of data. The challenge for us and for other researchers is to perform more such analyses and extend and refine the techniques described here and to link the analyses to those from other domains.
... Human and organizational errors stand for unanticipated or undesirable effects due to bad performance of an individual or a group within an organisation. Senders and Moray defined human error as a behaviour which van be observed, the origin of the which are processes on different levels where performance standards are needed for its evaluation and it is initiated by an event where there was a possibility to act in another way but correctly (Senders & Moray, 1991). Hollnagel states that human error can only be observed by observing first human behaviours. ...
Conference Paper
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Advances in science and technology have enabled people the access to gadgets that facilitate their business and personal life. Mobile devices are the most popular form of communication and because of their advanced features and relatively poor security have become attractive targets for attackers. Defensive layers are present in such systems, some are automated and engineered while others rely on people. Their function is to protect potential victims and assets from local hazards. Mostly they do this very effectively, but there are always weaknesses because of the vulnerabilities presented as 'holes' in Swiss Cheese Model (SCM). This work aims to introduce the adoption of SCM in organisations where these devices are used, by explaining how human factor can lead to errors and what is the contribution of latent conditions in 'holes'. Here it is shown that SCM has its limitations and to make good use and enhance of it, Failure Mode and Effects Analysis (FMEA) is suggested for manufacturer side. Through this quantitative analysis tool it is shown how its application can contribute in risk mitigation in mobile devices systems.
... Human unreliability is related to the fields of human factors and ergonomics but may also be affected by many factors such as age, state of mind, health, workplace conditions, propensity for making mistakes, etc. (Senders & Moray, 1991;Jones, 1999). ...
Article
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Myriad reasons exist as to why humans make mistakes in the workplace. Certain factors such as job stress, management style, workplace culture, workplace design, attendance, and employee attitude, for example, play crucial roles in one's ability to minimize or eliminate human errors. Whereas human error may occur as a result of choosing an inappropriate rule or by having an incomplete understanding of the system, human error may also be the result of mental slips, mental lapses, or distractions. This paper consists of a five-month observational study with the objective being to identify various sources of human unreliability at a corrugated box manufacturer in Knoxville, Tennessee.
... The authors concluded that developing a curriculum which focused on problem-solving strategies may optimize responses to critical incidents [14]. Human errors defined as something having been done 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 acceptable limits [15]. James Reason stated that human error can be looked at in two approaches, the person and the system [16]. ...
Article
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Purpose of review Reliable data indicates increasing numbers of patients are harmed when receiving healthcare. The landmark paper “To Err is Human” posited that adverse events occur in the context of the complexity of systems within medicine and are not due to intentional harm. Crisis resource management (CRM) originated in aviation in 1980. CRM is defined as the cognitive, social, and personal resource skills that complement technical skills and contribute to safe task performance. It is a risk-reducing strategy utilized in aviation that has led to significant reduction in human error–related airline fatalities. CRM was adopted from commercial aviation by medicine in 1990 in an attempt to improve patient safety and reduce morbidity and mortality attributed to medical errors. Recent findings In the last 40 years, commercial and military aviation has standardized CRM training which has led to a track record of success in improving safety for flight crews and passengers with flight-related mortality significantly decreasing. In stark contrast, nearly 30 years of CRM training in healthcare has been highly variable in content, quality, and outcomes. In this time, the number of patient deaths attributed to medical mistakes has increased from an estimated 50,000–100,000 in 1999 to over 250,000 per year from a 2016 estimate. Summary It is time to reassess how CRM is being deployed in healthcare. Full CRM integration will require significant cultural and embedded organizational changes. Proficient CRM skills are a necessary, but not sufficient, condition for adverse event rate reduction: CRM should not be just what we do—it has to be a part of who we are as medical professionals.
... Poorly organized teamwork can lead to misunderstandings, poor decision-making, loss of time, technical problems, or errors. These malfunctions are intraoperative adverse events which are defined as "something that was not intended by the surgeon, nor desired by a set of rules or an external observer, or that led the task outside acceptable limits" [5]. Non-technical errors may be associated with intraoperative adverse events and also may influence clinical outcomes [6,7]. ...
Article
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Background Robotic surgery requires a set of non-technical skills (NTS), because of the complex environment. We aim to study relationship between NTS and near-miss events in robotic surgery. Methods This is an observational study in five French centers. Three robotic procedures were observed and filmed by one of expert trainers in NTS. They established and scored a non-technical skills in robotic surgery (NTSRS) score, that included eight items, each scored from 1 to 5, to assess the whole surgical teams. The surgical teams also self-assessed their work. The number of near-miss events was recorded and classified as minor, or major but no harm incidents, independently by two surgeons. Correlations were Spearman coefficients. Results Of the 26 procedures included, 15 were prostatectomy (58%), 9 nephrectomy (35%), and 2 pyeloplasty (7.7%). Half of procedures (n = 13) were performed by surgeons with extensive RS experience (more than 150 procedures). Per procedure, there was a median (quartiles) of 9 (7; 11) near-miss events. There was 1 (0; 2) major near-miss events, with no harm. The median NTSRS score was 18 (14; 21), out of 40. The number of near-miss events was strongly correlated with the NTSRS score (r = − 0.92, p < 0.001) but was not correlated with the surgeon’s experience. The surgeons for fifteen (58%) procedures, and the bed-side surgeons for 11 (42%) procedures, felt that there was no need for an improvement in the quality of their NTS. None of the surgeons gave a negative self-evaluation for any procedure; in three procedures (12%), the bed-side surgeons self-assessed negatively, on ergonomics. Conclusion Occurrence of near-miss events was reduced in teams managing NTS. Specific NTS surgical team training is essential for robotic surgery as it may have a significant impact on risk management.
... Rasmussen 1997;Leveson 2004;Dekker 2002;Hollnagel 2014). While these debates began over thirty years ago (Senders and Moray 1991) they remain unresolved. Whilst systems thinking perspectives are experiencing something of a resurgence in EHF , this perspective is yet to flow through to the media or justice systems (e.g. ...
Article
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This paper reviews the key perspectives on human error and analyses the core theories and methods developed and applied over the last 60 years. These theories and methods have sought to improve our understanding of what human error is, and how and why it occurs, to facilitate the prediction of errors and use these insights to support safer work and societal systems. Yet, while this area of Ergonomics and Human Factors (EHF) has been influential and long standing, the benefits of the ‘human error approach’ to understanding accidents and optimising system performance have been questioned. This state of science review analyses the construct of human error within EHF. It then discusses the key conceptual difficulties the construct faces in an era of systems EHF. Finally, a way forward is proposed to prompt further discussion within the EHF community. Practitioner statement: This state-of-science review discusses the evolution of perspectives on human error as well as trends in the theories and methods applied to understand, prevent and mitigate error. It concludes that, although a useful contribution has been made, we must move beyond a focus on individual error to systems failure to understand and optimise whole systems.
... Brief introduction EVITA method A TARA method in the EVITA project which concerns issues in four aspects (operational, safety, privacy, and financial) [15] TVRA reat, vulnerabilities, and implementation risk analysis method, which is a process-driven threat and risk assessment method developed by the European Telecommunications Standards Institute (ETSI) [10] OCTAVE Operationally critical threat, asset, and vulnerability evaluation method, which is suitable for enterprise information security risk assessment [10] HEAVENS security model A TARA method in the HEAling vulnerabilities to enhance software (HEAVENS) project, which is based on Mircosoft's STRIDE threat model and focuses on the method, process, and tool support for TARA [10] Attack trees A method for vulnerability analysis, which identifies attack goals, objectives, methods, and attack scenarios of the target system [10] SW vulnerability analysis A method to find vulnerabilities in codes [10] SHIELD A method to analysis security, privacy, and dependability (SPD) for the embedded system by using control science theory [18] NHTSA method A threat modelling approach by using threat matrix in the technical report of U.S. National Highway Traffic Safety Administration (NHTSA) [19] BRA e binary risk analysis method which is a lightweight risk analysis tool for a quick assessment and used as a part of other TARA processes like OCTAVE [20] NIST SP 800-30 A risk assessment guide proposed in NIST SP 800-30 and applicable to identify, estimate, and prioritize risks for a large range of security-critical targets [21] functionality caused by the insufficient design of the system also belong to this category. e factor "Human" is divided into "Human Errors" and "Misuse by Human.". e former means that something has been done not intended by the actor and may lead system outside its acceptable limits [35], while the latter refers to the usage of the system by a person in a way not intended by the manufacturer [2]. e third factor 'Environment' contains external physical conditions, like temperature and humidity, and system prerequisites, like correct data inputs from sensors. ...
Article
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With the increasing connectivity of modern vehicles, protecting systems from attacks on cyber is becoming crucial and urgent. Meanwhile, a vehicle should guarantee a safe and comfortable trip for users. Therefore, how to design a cybersecurity-critical system in vehicles with safety and user experience (UX) considerations is increasingly essential. However, most co-design methods focus on safety engineering with attack concerns and do not discuss conflicts and integration, and few contain the UX aspect. Besides, most existing approaches are abstract at a high level without practical guidelines. This paper presents a literature review of existing safety and security design approaches and proposes a systematic approach for cybersecurity design of in-vehicle network systems based on the guideline in SAE J3061. The trade-off analysis is performed by using association keys and the proposed affecting map. The design process of an example Diagnostic on Internet Protocol (DoIP) system is reported to show how the approach works. Compared with the existing approaches, the proposed one considers safety, cybersecurity, and UX simultaneously, solves conflicts qualitatively or quantitatively, and obtains trade-off design requirements. This approach is applicable to the cybersecurity-driven design of in-vehicle network systems in the early stage with safety and UX considerations.
... Sometimes the errors are caused by stress or exhaustion of the user. Sometimes the errors are because of an estimation and sometimes wrong pressing a button can lead to a humanitarian disaster (Dong et al., 2013;Moray and Senders, 1991). Human errors may be negligible and their effects on daily life can be ignored, but this is only possible until human lives are not at stake. ...
... Sometimes the errors are caused by stress or fatigue of the user. Sometimes they occur during estimation and sometimes wrong pressing a button can lead to a humanitarian disaster [1,2]. Human errors may be negligible, and their effects on daily life can be ignored, but this is only possible until human lives are not at stake. ...
Preprint
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Humans can be replaced by artificial intelligence-based approaches in many applications to reduce the probability of human errors. These approaches can also help us predict some events by analyzing data that seems to be unimportant. The overwhelming crash of flight 752 of Ukrainian International Airlines by the Iranian air defense systems in the early days of 2020 has prompted us more to explain the need to use artificial intelligence to prevent such events. This study attempts to calculate the likelihood of airline hazards based on artificial intelligence to warn decision-makers of the occurrence of potential accidents before flights. As a case study, we investigate the proposed method on flight 752 to explain its usefulness in great details. This study was designed to gain further insights into the use of artificial intelligence in risk estimation and can be criticized or modified.
... The classical view of human error is characterized by a negative evaluation of erroneous behavior that must be avoided [1]. In the literature, many attempts were reported to identify and classify human causes of error [2][3][4]. Although there is no one strict definition of human error, most attempts to define it have agreed that it involves some degree of deviation. ...
Chapter
The main challenge that can impact the effectiveness of authentication mechanisms is human error (unintentional threats). Irrational judgment associated with human error is often linked to a unique attribute called cognitive bias (CB). CB is a tendency to think irrationally in certain situations and make irrational judgment. The appearance of CB in human decisions is considered one of the implications of system usability. In the security filed, usability is recognized as one of the main issues that affect an individual’s security decisions. Clearly, security decision-making is a result of three overlapping factors: security, usability and CB. In this paper, we quantify security decision making by providing a holistic view on how these factors affect the security decision. For this purpose, an experiment was conducted involving 54 participants who performed multiple security tasks related to authentication. An eye-tracking machine was used to record cognitive measurements that were used for decision analysis. Multi Criteria Decision Analysis (MCDA) approach was then used to evaluate the participants’ decisions. The result showed that participants security decisions are varied depends on the authentication method. For instance, picture type was the authentication method least influenced by CB. Low system usability is one of the major causes of CB in decisions. This was not the case for the picture password method. The different levels of usability associated with the picture method resulted in low impact of CB on participants’ security decision. This finding point to investigating how picture-based authentication methods are capable of handling the issue of the CB.
... Human error has been attributed as a major cause of accidents and performance losses in complex engineered systems [1][2][3][4]. On average, 60% to 80% of all aviation accidents are * Contact author: onan.demirel@oregonstate.edu caused by human error [5]. ...
Conference Paper
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Human errors and poor ergonomics are attributed to a majority of large-scale accidents and malfunctions in complex engineered systems. Human Error and Functional Failure Reasoning (HEFFR) is a framework developed to assess potential functional failures, human errors, and their propagation paths during early design stages so that more reliable systems with improved performance and safety can be designed. In order to perform a comprehensive analysis using this framework, a wide array of potential failure scenarios need to be tested. Coming up with such use cases that can cover a majority of faults can be challenging or even impossible for a single engineer or a team of engineers. In the field of software engineering, automated test case generation techniques have been widely used for software testing. This research explores these methods to create a use case generation technique that covers both component-related and human-related fault scenarios. The proposed technique is a time based simulation that employs a modified Depth First Search (DFS) algorithm to simulate events as the event propagation is analyzed using HEFFR at each timestep. This approach is applied to a hold-up tank design problem and the results are analyzed to explore the capabilities and limitations.
... those launching startups) or mature entrepreneurs seeking new business opportunities. Senders and Moray (1991) described an error as the act that is "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" (p. 25). ...
Article
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Purpose This study aims to understand and compare how the mechanism of innovative processes in the information technology (IT) industry – the most innovative industry worldwide – is shaped in Poland and the USA in terms of tacit knowledge awareness and sharing driven by a culture of knowledge and learning, composed of a learning climate and mistake acceptance. Design/methodology/approach Study samples were drawn from the IT industry in Poland ( n = 350) and the USA ( n = 370) and analyzed using the structural equation modeling method. Findings True learning derives from mistake acceptance. As a result of a risk-taking attitude and critical thinking, the IT industry in the USA is consistently innovation-oriented. Specifically, external innovations are highly correlated with internal innovations. Moreover, a knowledge culture supports a learning culture via a learning climate. A learning climate is an important facilitator for learning from mistakes. Originality/value This study revealed that a high level of mistake acceptance stimulates a risk-taking attitude that offers a high level of tacit knowledge awareness as a result of critical thinking, but critical thinking without readiness to take a risk is useless for tacit knowledge capturing.
... The term error has a range of meanings in the literature (Senders & Moray, 1991); one possible interpretation is that there is a discrepancy between a student's current understanding and the scientific knowledge previously presented in instruction (Kobi, 1994). Recent views on errors consider them as natural element in classroom settings and emphasize the key role for cognitive and affective outcomes. ...
Article
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Dealing with student errors is a central feature of instructional quality. Teachers' reactions to a student's error and classmates' errors can be crucial to the success of a lesson. A teacher should respond appropriately in terms of motivational and learning-related issues so that the error can become a learning opportunity for students. Currently, error situations have rarely been directly recorded and explored in empirical zstudies. This gap is the central focus of the current study in which we investigated errors in biology instruction within a cross-sectional design where biology lessons in German secondary schools were videotaped, teachers' dealings with errors analyzed, and student achievement documented with pretests and posttests. The study found that constructively dealing with student errors had a significant positive effect on student achievement at the class level. Results confirmed the relevance of teachers' appropriate dealing with student errors on learning in biology instruction.
... As human beings we are intrinsically wired to make mistakes despite our best effortsit is in our nature (Shappell & Wiegmann, 1997). Human error can be defined as an action that results in consequences that were unintended or undesired by an applicable set of safety standards, or causes a system to operate outside of stipulated and acceptable limits (Senders & Moray, 1991). ...
Thesis
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Background: Low morale is classified as a latent condition for performance variability in safety-critical environments. Morale management may assist in the control of performance variability as part of a systems approach to safety. A context-specific model for measuring and managing morale with reference to followership in a safety-critical air traffic control (ATC) environment could not be found. Purpose/Aim: The purpose of this study was to develop a model that enables the measurement and management of air traffic controller (ATCO) team morale. Research Design: An exploratory sequential mixed method design was adopted. A census approach to sampling was used to conduct 21 focus group sessions as the qualitative phase, providing the definition and drivers of morale. The Measure of Morale and its Drivers (MoMaD) survey instrument was created from qualitative data, then administered to 256 ATCOs in the quantitative phase. Statistical methods included exploratory factor analysis, correlation and regression analysis to construct the final MoMaD model. Results: A context-specific definition of morale is provided and communication management, team cohesion, leadership interaction, staff incentive, staffing level, workplace health and safety and mutual trust were found to be the drivers of morale in a safety-critical ATC environment. A single-item measure of perceived morale reflected the state of context-specific ATCO team morale more accurately than an existing generalisable multi-item measure. Conclusion: This study contributes to the body of knowledge by integrating applicable aspects of morale, followership, performance variability and organisational culture and climate in safety-critical ATC environments into a new theoretical framework. The MoMaD instrument is presented as a context-specific model for measuring and managing ATCO team morale in an ATC environment. Recommendations: Future research opportunities include the possible influence of morale as a predictor of morale in safety-critical environments and the development of a context-specific multi-item measure of morale for integration into the MoMaD model. Key terms: morale; followership; human error; human performance variability; air traffic control; aviation; corporate culture; safety culture; esprit de corps; motivation
... In the mid-90s, a vision of the future of ergonomics was put forward by [161], when he argued that given the historical situation at the time, ergonomics was going to be looked at as a way to facilitate the improvement of the quality of life, as a partner in a multidisciplinary approach that would allow, entice, and enforce behavioral change that would benefit not only businesses, but the world at large. He mentioned that "ergonomics also, needed to accept the fact that few solutions are universal, as solutions need to acknowledge the morals and the ethics of place". ...
Chapter
Technology has disrupted each current industry, and supply chain is not going to be an exception. Businesses are already starting to establish interconnected global networks of Cyber-Physical Systems with the help of the Internet of Things and Cloud Computing. In this context, the chapter will debate aspects related to the new challenges of reducing ergonomics risks in manufacturing warehouse logistics by valorizing emerging technologies to create workplace wellbeing. After an extended literature review regarding the relevant ergonomics approaches in warehouse logistics, there will be presented some warehouse ergonomics solutions to be considered for the next generation of logistics system. The solutions described will refer to the monitoring and improvement of the ergonomic reality. Finally, conclusions and future trends will end the chapter.
... Bhavsar et al. [2] argued that human error was one of the major reasons for industrial accidents, emphasizing the need to introduce new technologies to prevent it. Dinges [3] also stated that unintentional human errors in the workplace, which can include mistakes by operators, maintenance, and management, were the most frequently identified root causes of accidents, contributing significantly to between 30% and 90% of all serious incidents across industries [4,5]. In a similar vein, Hals [6] found that human error was a primary causal factor in 70-80% of accidents in the oil and gas industry. ...
Article
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The accident rate due to human errors in industrial fields has been consistently high over the past few decades, and noise has been emerging as one of the main causes of human errors. In recent years, auditory pre-stimulation has been considered as a means of preventing human errors by improving workers’ cognitive task performance. However, most previous studies demonstrated the effectiveness of the auditory pre-stimulation in a quiet environment. Accordingly, studies on the effects of pre-stimulation in a noisy environment are still lacking. Therefore, this study aimed to empirically investigate: (1) the effects of noisy environments on the performances of cognitive tasks related to different functions of working memory and (2) the effects of auditory pre-stimulation on the performances of cognitive tasks in a field-noise environment. To accomplish these research objectives, two major experiments were conducted. In the first experiment, a total of 24 participants performed each of three basic short-term/working memory (STM/WM) tasks under two different experimental conditions (quiet-noise environment and field-noise environment) depending on the presence or absence of field noise. In the second experiment, the participants performed each of the three basic STM/WM tasks in a field-noise environment after they were provided with one of four different auditory pre-stimulations (quiet noise, white noise, field noise, and mixed (white and field) noise). The three STM/WM tasks were the Corsi block-tapping, Digit span, and 3-back tasks, corresponding to the visuospatial sketchpad, the phonological loop, and the central executive of WM, respectively. The major findings were that: (1) the field-noise environment did not affect the scores of the Corsi block-tapping and 3-back tasks, significantly affecting only the Digit span task score (decreased by 15.2%, p < 0.01); and (2) the Digit span task performance in the field-noise environment was improved by 17.9% (p < 0.05) when mixed noise was provided as a type of auditory pre-stimulation. These findings may be useful for the work-space designs that prevent/minimize human errors and industrial accidents by improving the cognitive task performance of workers in field-noise environments.
... • Personalisation: aspect that offers the users the possibility to customise how information is presented to them (Wiens et al. 2020). • Error prevention: aspect that improves user experience by preventing users from making mistakes (Senders and Moray 1991). • Information architecture: way in which users organise and structure the information available with the aim to favour the design of intuitive interfaces and minimise the user errors (Plaisant et al. 1998). ...
Article
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Visualisations are often the entry point to information that supports stakeholders’ decision- and policy-making processes. Visual displays can employ either static, dynamic or interactive formats as well as various types of representations and visual encodings, which differently affect the attention, recognition and working memory of users. Despite being well-suited for expert audiences, current climate data visualisations need to be further improved to make communication of climate information more inclusive for broader audiences, including people with disabilities. However, the lack of evidence-based guidelines and tools makes the creation of accessible visualisations challenging, potentially leading to misunderstanding and misuse of climate information by users. Taking stock of visualisation challenges identified in a workshop by climate service providers, we review good practices commonly applied by other visualisation-related disciplines strongly based on users’ needs that could be applied to the climate services context. We show how lessons learned in the fields of user experience, data visualisation, graphic design and psychology make useful recommendations for the development of more effective climate service visualisations. This includes applying a user-centred design approach, using interaction in a suitable way in visualisations, paying attention to information architecture or selecting the right type of representation and visual encoding. The recommendations proposed here can help climate service providers reduce users’ cognitive load and improve their overall experience when using a service. These recommendations can be useful for the development of the next generation of climate services, increasing their usability while ensuring that their visual components are inclusive and do not leave anyone behind.
... In practice, we expect this study will provide hospitality practitioners with valuable insights into how to make the best use of these two conflicting cultures in error-prone hospitality operations. litErAturE rEviEw AnD rEsEArCH HypotHEsEs organizational Error Culture: Error Aversion versus Error Management Errors, or deviations from rules, have undesirable consequences (Senders & Moray, 1991). To scale error, Reason (2000) conceptualized two categories of errors-systematic and personal. ...
Article
This study examines how two error cultures (error management and error aversion) influence customer-oriented behavior through negative affectivity and job satisfaction. We collected two samples: one for the error-aversive scale validation ( n = 140) and the other for the conceptual model ( n = 381). All responses are from contact employees working for mid-scale to luxury hotels in a metropolitan city in China. The findings reveal that mid-scale hotels are more error-averse than upscale hotels; upscale and luxury hotels are more inclined to error-management than mid-scale hotels. Further, error strains and error cover-up do not converge as lower-order constructs for error aversion; cover-up appears to be the truly opposite of error management. Cover-up along with strains decreases customer-oriented behavior through negative affectivity. In contrast, error management increases customer orientation through job satisfaction. This study contributes to the literature of organizational error culture by incorporating two opposite error cultures into the proposed model.
... To get a better understanding of humans' errors, various attempts have been made for clarifying this concept, yet no generally accepted definition has been reached [55]. Although several definitions have been introduced (e.g., [59,55]), we adopt the one proposed by Reason [50] that defined human error as "a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency". Based on this definition, Salmon et al. [55] concluded that human error can, therefore, be generally defined as any mental or physical activity, or failure to perform the activity, that leads to either an undesired or unacceptable outcome. ...
Article
Several approaches have been developed to assist automotive system manufacturers in designing safer vehicles by facilitating compliance with functional safety standards. However, most of these approaches either mainly focus on the technical aspects of automotive systems and ignore the social ones, or they provide inadequate analysis of such important aspects. To this end, we propose a model-based approach for modeling and analyzing the Functional Safety Requirements (FSR) for automotive systems, which considers both the technical and social aspects of such systems. This approach is based on both the ISO 26262 and ISO/PAS 21448 standards, and it proposes a detailed engineering methodology to assist designers while modeling and analyzing FSR. In particular, this approach proposes a UML profile for modeling the FSR of the automotive system starting from item definition until safety validation, and it offers constraints expressed in Object Constraint Language (OCL) to be used for the verification of FSR models. We demonstrated the applicability and usefulness of the approach relying on a realistic example from the automotive domain, and we also evaluated the usability and utility of the approach with potential end-users.
... Human error can be defined as "a deviation from expected human performance, where the person that arbitrates did the error occurred has to have criterion what is and what is not an error. This distinction concerns whether human behavior alone is examined or the performance of the humanmachine system as a whole" [7]. In other words, the seafarer has to understand how to perform their duties to carry out any given job safely and efficiently. ...
Article
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Safety leadership is critical in high-risk industries such as shipping since inadequate leadership can cause marine accidents, resulting in injuries, fatalities, damage to property and environmental pollution. One of the aspects of good and effective safety leadership is creating good human relations and satisfaction among crewmembers, considered a precondition for effective teamwork. Officers on board ships should establish effective teamwork and implement adequate safety leadership, positively affecting safety culture, increasing safety in general and improving marine environment protection. Safety leadership onboard ships comprises several characteristics, including maintaining safe work performance, carrying out safety training, and encouraging crewmember morale. Therefore, it is essential for all stakeholders in shipping industries that officers onboard ships can identify those characteristics, adapt, and apply them adequately. This paper presents the characteristics and skills that shipboard officers need to apply in order to be excellent leaders and serve with adequate safety leadership abilities. One tool for recognizing those characteristics and skills was a survey carried out among experienced professional seafarers. Analysis of the survey data revealed latent factors, these being transformational and transactional leadership elements affecting safety leadership onboard ships.
... This state reduces efficiency and drastically increases the probability of making mistakes. Detecting and preventing situations of cognitive overload is crucial when applied to the study of operators whose errors can cause serious harm, as is the case in the industrial (nuclear), transportation (maritime, car, aviation), military and medical fields (McFadden et al., 2004;Senders & Moray, 2020). Valid and sensitive methods for measuring CWL continuously and in real time are thus indispensable. ...
Article
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Cognitive workload (CWL) is a fundamental concept in the assessment and monitoring of human performance during cognitive tasks. Numerous studies have attempted to objectively and continuously measure the CWL using neuroimaging techniques. Although the electroencephalogram (EEG) is a widely used technique, the impact of CWL on the spectral power of brain frequencies has shown inconsistent results. The present review aimed to synthesize the results of the literature and quantitatively assess which brain frequency is the most sensitive to CWL. A systematic literature search following PRISMA recommendations highlighted three main frequency bands used to measure CWL: theta (4–8 Hz), alpha (8–12 Hz), and beta (12–30 Hz). Three meta‐analyses were conducted to quantitatively examine the effect of CWL on these frequencies. A total of 45 effect sizes from 24 studies involving 723 participants were computed. CWL was associated with significant effects on theta (g = 0.68, CI [0.41, 0.95]), alpha (g = −0.25, CI [−0.45, 0.04]), and beta (g = 0.50, CI [0.21, 0.79]) power. Our results suggests that theta, especially the frontal theta, is the best index of CWL. Alpha and beta power were also significantly impacted by CWL; however, their association seemed less straightforward. These results are critically analyzed considering the literature on cerebral oscillations. We conclude by emphasizing the need to investigate the interaction between CWL and other factors that may influence spectral power (e.g., emotional load), and to combine this measure with other methods of analysis of the central and peripheral nervous system (e.g., functional connectivity, heart rate). Our study provides the first quantitative synthesis of the impact of cognitive workload (CWL) on EEG spectral power. Our meta‐analysis and moderator analysis reveal that the theta frequency of the frontal cortex is the most sensitive index of CWL, while alpha and beta frequencies are also sensitive to increasing load.
... El estudio del error humano ha sido un tema de interés en varios sectores (aviación, militar, espacial, nuclear) y en especial en el sector sanitario. Aunque existen varias definiciones de error humano [1,2], la mayoría coincide en asumirlo como el efecto de algo que los humanos hacen o pretenden hacer, y que conduce a resultados diferentes de los esperados. La definición de James Reason es una de las que con mayor claridad expresa la esencia de lo que se considera error humano: "Un término genérico empleado para abarcar todas aquellas ocasiones en las que una secuencia planificada de actividades mentales o físicas fallan en alcanzar el resultado esperado, y cuando estos fallos no pueden atribuirse a la intervención del azar" [3, p. 9]. ...
Article
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Los errores de medicación representan un problema de salud pública que afecta la seguridad del paciente y la calidad de los servicios de salud a escala global. En este artículo se presenta un procedimiento para el análisis y la prevención de los errores de medicación desde la perspectiva de la ergonomía, ejemplificándose su aplicación mediante un caso de estudio ilustrativo de administración de un medicamento inyectable. Como parte del procedimiento expuesto, se incluyeron los reconocidos métodos Hierarchical Task Analysis (hta) para el análisis de la tarea y Systematic Human Error Reduction and Prediction Approach (sherpa) para la identificación de los modos de error. Para la valoración de riegos se propone una matriz de riesgos cualitativa. El procedimiento propuesto quedó conformado por cuatro etapas: 1) selección de la tarea objeto de estudio, 2) análisis detallado de la tarea, 3) predicción de la posibilidad de error y 4) desarrollo de estrategias para la reducción del error. Se espera que la utilización sistemática de este procedimiento contribuya en la mejora de la calidad de los servicios de salud, disminuyendo los errores humanos y los posibles eventos adversos
... My advisor, Neville Moray, introduced me to John Senders over 25 years ago through John's work on human error and models of monitoring behavior (Senders & Moray, 1991;Senders, 1964). Later, Neville introduced me in person and I learned more about his wide-ranging interests and the pure enjoyment he took in thinking about and modeling the world. ...
Article
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This session looks to serve the purpose of recalling and recounting the life and contributions of Professor John Senders. The contributors to this session include his direct colleagues, his students, his co-authors, those whom he inspired, and even members of his family. These designations are not exclusive! Senders made so many contributions across virtually a century of his lifetime that we are constrained to provide only selective highlights in this memorial session, such as John being named the winner of an “Ig-Nobel” Award. We shall each survey particular works which influenced us, but interweave those observations with personal experiences that can serve to reveal John the character, who was so much more than the simple written record that he has left behind.
... Referring to the Management of Health and Safety at Work Regulation 1992 (MHSWR 1992) and the Control of Substances of Hazardous to Health andRegulations 1999 (COSHH 1999), the risk management analysis for the pneumatic tube system includes the suitability of the specimen to be transported, pneumatic tube design that is strong and safe from leakage, packing of specimens that is in accordance with procedures, and procedures to be carried out in the event of leakage or spilled specimens, as well as providing training, information, and complete instructions regarding the pneumatic tube system (12). ...
... There was a before-dinner sherry hour, dinner, after dinner drinks, and a music recital by members of the local music seminary with attendance required at all these events. John and Neville Moray summarized the discussions in their book (Senders & Moray, 1995), but that Norman says does not match his memory of the event. But then again, with all that food and drink, who knows what really happened? ...
Article
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Objective To honor the legacy of John Senders, a distinguished member of the Human Factors and Ergonomics Society, by a short, personal history of him, but then to honor his legacy by extending it through our own professional opinions, with an emphasis on the study of human error and its implications for healthcare systems—two topics in which he excelled. Background The authors are familiar with the topic and subject matter. One was a friend of Senders for over 50 years. Another was a collaborator and joint author with Senders (as well as his stepdaughter). All three authors have extensive publications in the topic areas. Method, Results, and Conclusion The authors used personal accounts of interactions with Senders at conferences, experiences living and working with him, and a brief review of his most personal, notable publications in healthcare. The reflections indicate a strong resonance on Senders’ contributions to system design that are relevant today in healthcare’s most challenging period in its history.
... Human error is defined as: "A deviation from expected human performance, where the person that arbitrates did the error occurred has to have criterion what is and what is not an error. This distinction concerns whether the human behavior is examined alone, or the performance of the human-machine system as a whole" (Senders and Moray, 1991). In other words, an individual has to know what is expected from him to perform any given task correctly and efficiently. ...
Conference Paper
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Inadequate leadership is one of the factors that can cause maritime accidents and thus affect human lives and the environment. An overview of maritime accidents caused by inadequate leadership and human relations among a ship's team members is presented in this paper. Good human relations and satisfaction among all ship's team members are preconditions for effective teamwork. Ship's masters should establish effective teamwork in order to implement an adequate leadership style and increase safety on board ships. Knowledge of factors that can be crucial for implementing a proper leadership style can serve as a motivator for better work performance and stimulate the morale, especially in the case of maritime accidents that have an evacuation of the vessel as a consequence. Implementations of positive characteristics and methods that can serve as guidelines and keys to successful leadership on board ships are introduced in this paper. Senior ship officers were asked to fill out a questionnaire ranking characteristics of leadership qualities. Important characteristics of leadership skills are summarized from the questionnaire analysis.
Preprint
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Errors in botanical surveying are a common problem. The presence of a species is easily overlooked, leading to false-absences; while misidentifications and other mistakes lead to false-positive observations. While it is common knowledge that these errors occur, there are few data that can be used to quantify and describe these errors. Here we characterise false-positive errors for a controlled set of surveys conducted as part of a field identification test of botanical skill. Surveys were conducted at sites with a verified list of vascular plant species. The candidates were asked to list all the species they could identify in a defined botanically rich area. They were told beforehand that their final score would be the sum of the correct species they listed, but false-positive errors counted against their overall grade. The number of errors varied considerably between people, some people create a high proportion of false-positive errors, but these are scattered across all skill levels. Therefore, a person’s ability to correctly identify a large number of species is not a safeguard against the generation of false-positive errors. There was no phylogenetic pattern to falsely observed species, however, rare species are more likely to be false-positive as are species from species rich genera. Raising the threshold for the acceptance of an observation reduced false-positive observations dramatically, but at the expense of more false negative errors. False-positive errors are higher in field surveying of plants than many people may appreciate. Greater stringency is required before accepting species as present at a site, particularly for rare species. Combining multiple surveys resolves the problem, but requires a considerable increase in effort to achieve the same sensitivity as a single survey. Therefore, other methods should be used to raise the threshold for the acceptance of a species. For example, digital data input systems that can verify, feedback and inform the user are likely to reduce false-positive errors significantly.
Article
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Like a vision in the future of transportation, autonomous vehicles (AVs) are becoming a familiar aspect to debate from different perspectives which consist of design, social issues, security and safety, and so on. Besides, autonomous vehicles ‘evolution creates a new era in replacing the human being behind the steering wheel by sensors, artificial intelligence , and auto robotics. Moreover, it is also a novel technology which can reduce fatal vehicle accidents and deaths. However, it also brings several drawbacks for customers. In this article, the authors described the general view of autonomous challenges before it can apply in public transportation. Furthermore, it enhances the awareness of the manufacturers to focus on figuring out solutions to guarantee the safety and security for AVs.
Article
Objective To provide an evaluative and personal overview of the life and contributions of Professor John Senders and to introduce this Special Issue dedicated to his memory. Background John Senders made many profound contributions to HF/E. These various topics are exemplified by the range of papers which compose the Special Issue. Collectively, these works document and demonstrate the impact of his many valuable research works. Method The Special Issue serves to summarize Senders’ collective body of work as can be extracted from archival sources. This introductory paper recounts a series of remembrances derived from personal relationships, as well as the products of cooperative investigative research. Results This collective evaluative process documents Senders’ evident and deserved status in the highest pantheon of HF/E pioneers. It records his extraordinary life, replete with accounts of his insights and joie de vivre in exploring and explaining the world which surrounded him. Applications Senders’ record of critical contributions provides the example, par excellence, of the successful and fulfilling life in science. It encourages all, both researchers and practitioners alike, in their own individual search for excellence.
Article
Purpose Given the importance of food wastes in households, the purpose was to identify the attitudes of young consumers towards the food sharing (FS) phenomenon in its cognitive, emotional and behavioral dimensions and to verify the reliability of the FAB (food sharing attitudes and behaviors) model, used as a research tool. Design/methodology/approach The study was conducted in 2021 using the computer assisted web interview (CAWI) method. The FAB model was based on the ABC (affect, behavior and cognition) model of attitudes, which includes three components: affect, behavior and cognition. Questions on the phenomenon of FS were scaled on a 5-point Likert scale. A total of 469 correctly completed forms were obtained. To assess the reliability of the FAB model the Cronbach’s alpha was used. In the statistical analysis SPSS Statistics 27 was used. Findings Young consumers have a positive attitude towards the idea of FS and the initiative of FS points. Gender is a significant factor in FS attitudes. The FAB model has proven to be a reliable tool for exploring consumer attitudes towards FS. A set of activities was proposed to promote the idea of FS on university campuses and among other potential stakeholders. Originality/value To contribute to the body of knowledge on FS, the authors proposed the FAB model. The results of this study are relevant for reducing food wastes; they promote sustainable food consumption and the European Green Deal (EGD).
Thesis
Errors and adverse events are common in clinical practice, and have a significant impact on quality and safety issues. They are also a major source of complaints and litigation. However, the study of errors in nursing (apart from medication errors) has been a neglected area of research enquiry. As a result, very little is known of the interaction between professional, contextual, organisational and psychological factors in the production of errors and in their prevention. A series of studies were carried out to investigate the antecedents, types, and incidence of errors as well as nurses' responses to them, principally to identify the types of strategies that may be most effective in reducing errors in nursing care. Using a critical incident technique, the types of errors that were made by nurses and their responses to them were investigated. These were found to occur at various stages of the nursing process. Accepting responsibility for one's error was linked to constructive changes in their practice. The frequency of omissions in the assessment records of patients with chest pain was then examined. The assessment records were found to be very superficially completed and to contain a number of important omissions. When these omissions were compared with nurses' reported omissions, a wide discrepancy was observed. Nurses not only reported significantly less omissions but also attributed their causes mainly to external factors such as job overload rather than internal factors such as lack of knowledge or experience, although they could achieve only 50 % of the expected score in a recall test on chest pain. This may be because they may not have considered these omissions as errors. When they were presented with scenarios describing 'real' errors, they tended to attribute their causes predominantly to internal factors. On the basis of these findings, a system of care pathways was implemented for patients admitted with chest pain to ascertain whether this structured approach to care would be effective in reducing omissions in assessment and care of these patients. The results showed significant improvement in the assessment records of the patients as well as a positive impact on various clinical indicators, including better awareness of patients' needs and improved patients' satisfaction. The results of these studies have implications for the management of errors in nursing and for improving the standard of care given to patients. The evidence suggests that a system approach should be used both for investigating errors in nursing and for reducing their incidence.
Thesis
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System availability and efficiency are critical aspects in the oil and gas sector; as any fault affecting those systems may cause operations to shut down; which will negatively impact operation resources as well as costs, human resources and time. Therefore, it became important to investigate the reasons of such errors. In this study, software errors and maintenance are studied. End user errors are targeted after finding that is the number of these errors is projected to increase. The factors that affect end user behavior in oil and gas systems are also investigated and the relation between system availability and end user behavior are evaluated. An investigation has been performed following the descriptive methodology in order to gain insights into the human error factor encountered by various international oil and gas companies around the Middle East and North Africa. This was conducted by distributing a questionnaire to 120 employees of the companies in this study; 81 had responded. The questionnaire contained questions related to software/hardware errors and errors due to the end user. In short, the study shows that there is a relation between end user behavior and system availability and efficiency. Factors including training, experience, education, work shifts, system interface and I/O devices were identified in the study as factors affecting end user behavior. Moreover, the study contributes new knowledge by identifying a new factor that leads to system unavailability, namely memory sticks. This thesis presents a valuable knowledge that explains how errors occur and the reasons for their occurrence. Major limitations of this research include company policies, legal issues and information resources.
Chapter
Since the early 1990s, there has been a lot of enthusiasm for using high-speed connectivity to develop local community links through education, employment possibilities, fostering community events, and enhancing overall sociability within a local region. 5G is the 5th iteration of a broadband network operating on cellular systems. 5G is not only for mobile phones, but it is also the foundation for virtual reality (VR); the internet of things (IoT); and autonomous transport, immersive services, and public infrastructure; and connecting many electronic devices to the internet. In this chapter, first, the authors have discussed the evolution of 1G network to 6G networks by focussing on its potential impact on the quality of life. Further, 5G applications in IoT, autonomous transport, immersive services, and public infrastructure have been discussed. Then the chapter discusses popular advantages, limitations in the current technologies, implementations, and future perspectives.
Chapter
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To fail in a task, to misjudge a situation and to make wrong conclusions, or to be unable to achieve a desired goal, are basic human experiences that occur in everyday activities as well as in longer-term projects in the context of personal development. But the assessments of what is a mistake, an error, or a failure depend heavily on cultural as well as individual contexts. Errors, failures and mistakes do not constitute objectively ascertainable facts, but are subject to the validity of certain rules within a context-dependent judgement. These rules can exist in various forms and degrees of explicitness and are adopted in the course of social negotiation processes. The aim of this book is to synthesise empirical research-based and theoretical perspectives on mistakes, errors, and failure in and across cultures, in order to provide a comprehensive view of contemporary research and practice which is accessible to researchers and practicing professionals internationally.
Chapter
Misconduct is still widespread in banking. It often leads to economic and reputational losses and negatively affects trust in the economic and financial systems. Misconduct is mainly a result of errors in policies and procedures, of mistakes or malpractices in individual behaviours and of failure in management and control systems. Elaborating on the new theory of risk culture in banking, we develop a general framework of errors and failures in banking, on the basis of existing literature and taking into account the empirical evidence that is currently available. Particularly, we focus our attention on the influence of national cultures, the role of the organizational environment, errors and management practices and the impact on reputational risk role of banking regulators and supervisors in the handling of errors and mistakes. Our work helps demonstrate that culture is the main driver of organizational and individual behaviours and consequently of errors, mistakes and failures in bank management. Moreover, in a “sound” risk culture environment, the ability to manage errors must be in the toolkit of bankers and banking supervisors, enhancing cultural capital while preserving stability and efficiency of the whole financial system.
Article
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This article provides a historical and critical account of James Reason’s contribution to safety research with a focus on the Swiss cheese model (SCM), its developments and its critics. This article shows that the SCM is a product of specific historical circumstances, has been developed over a ten years period following several steps, and has benefited of the direct influence of John Wreathall. Reason took part in intense intellectual debates and publications in the 1980s during which many ideas circulated among researchers, featuring authors as influent as Donald Norman, Jens Rasmussen, Charles Perrow or Barry Turner. The 1980s and 1990s were highly productive from a safety research point of view (e.g. human error, incubation models, high reliability organisation, safety culture) and Reason has considerably influenced it with a rich production of models, based on both research and industrial projects. Historical perspectives offer interesting insights because they can question research, the conditions of its production, its relevance and, sometimes, its success, as for the SCM. But, because of this success, critics have vividly argued about some of the SCM limitations, including its simplistic vision of accidents and its degree of generality. Against these positions, the article develops a ‘critique of the criticism’, and the article concludes that the SCM remains a relevant model because of its systemic foundations and its sustained use in high-risk industries; despite of course, the need to keep imagining alternatives based on the mix of collective empirical, practical and graphical research which was in the SCM background.
Article
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Behavioral failures can serve as precursors for accidents. Yet, individual differences in the predisposition to behavioral failures have predominantly been investigated within relatively narrow parameters, with the focus limited to subsets of behaviors or specific domains. A broader perspective might prove useful in illuminating correlations between various forms of accidents. The current research was undertaken as one step toward developing the concept of behavioral failures proneness in its multidimensional aspect. We report the initial stage of the development and validation of the Failures Proneness questionnaire (FP): a brief, multifaceted, self-report scale of common behavioral failures in everyday settings. In a preliminary phase we conceived an extensive pool of prospective items. Study 1 identified and validated the factor-structure of FP and reduced the scale to a brief measure of 16 items. Study 2 corroborated the factor structure of the FP and evaluated its construct validity by assessing its relationship with the Five Factor Model (FFM) of personality traits. Study 3 tested the criterion-related validity of the FP by assessing its ability to predict deviant behaviors. These studies provide evidence of the FP’s performance in generating valuable information on a broad range of behavioral antecedents of accidents.
Article
Background An understanding of the impact of operative difficulty on operative process in laparoscopic cholecystectomy is lacking. The aim of the present study was to prospectively analyse digitally recorded laparoscopic cholecystectomy to assess the impact of operative technical difficulty on operative process. Methods Video of laparoscopic cholecystectomy procedures performed at Christchurch Hospital, NZ and North Shore Private Hospital, Sydney Australia were prospectively recorded. Using a framework derived from a previously published standard process video was annotated using a standardized template and stratified by operative grade to evaluate the impact of grade on operative process. Results 317 patients had their laparoscopic cholecystectomy operations prospectively recorded. Seventy one percent of these videos (n= 225) were annotated. Single ICC of operative grade was 0.760 (0.663 – 0.842 p<0.010). Median operative time, rate of operative errors significantly increased and rate of CVS decreased with increasing operative grade. Significant differences in operative anatomy, operative process and instrumentation were seen with increasing grade. Conclusion Operative technical difficulty is accurately predicted by operative grade and this impacts on operative process with significant implications for both surgeons and patients. Consequently operative grade should be documented routinely as part of a culture of safe laparoscopic cholecystectomy.
Preprint
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Errors in botanical surveying are a common problem. The presence of a species is easily overlooked, leading to false-absences; while misidentifications and other mistakes lead to false-positive observations. While it is common knowledge that these errors occur, there are few data that can be used to quantify and describe these errors. Here we characterise false-positive errors for a controlled set of surveys conducted as part of a field identification test of botanical skill. Surveys were conducted at sites with a verified list of vascular plant species. The candidates were asked to list all the species they could identify in a defined botanically rich area. They were told beforehand that their final score would be the sum of the correct species they listed, but false-positive errors counted against their overall grade. The number of errors varied considerably between people, some people create a high proportion of false-positive errors, but these are scattered across all skill levels. Therefore, a person’s ability to correctly identify a large number of species is not a safeguard against the generation of false-positive errors. There was no phylogenetic pattern to falsely observed species, however, rare species are more likely to be false-positive as are species from species rich genera. Raising the threshold for the acceptance of an observation reduced false-positive observations dramatically, but at the expense of more false negative errors. False-positive errors are higher in field surveying of plants than many people may appreciate. Greater stringency is required before accepting species as present at a site, particularly for rare species. Combining multiple surveys resolves the problem, but requires a considerable increase in effort to achieve the same sensitivity as a single survey. Therefore, other methods should be used to raise the threshold for the acceptance of a species. For example, digital data input systems that can verify, feedback and inform the user are likely to reduce false-positive errors significantly.
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