Cognitive Systems

Engineering

How Human-Artifact
Interaction should be
designed ?
Human error taxonomy

 What is human error (HE) ?

 Definition and classification of HE

 Consequence
 Manifestation
 Cognitive mechanism
 Causal factors
Taxonomy by consequence

 Consequence of human action

 Actual damage
 Latent risk  more important for prevention
 Heinrich’s law
 accidents : small troubles : near misses
= 1 : 29 : 300
 Reporting and countermeasure for near mis
ses are important. (e.g. ASRS)
Swiss cheese model of defenses

Local triggers
Intrinsic defects
Latent failures at the Atypical conditions
managerial levels

Trajectory of
accident opportunity
Psychological
precursors

Unsafe acts
Defence-in-depth J. Reason
Taxonomy by manifestation

 Human action that deviated from the

procedure: a normative sequence of
actions.
 Based on the assumption that single order
of actions is allowable.
Error mode of THERP

 Omission : lack of an expected action

 Commission : improper action execution
 Unnecessary action
 Wrong order of action sequence
 Improper timing
 Wrong object or direction
 Improper intensity or duration
Logical phenotype

S te p S te p i -1 S te p S te p S te p S te p S te p i -1 S te p S te p S te p
i-2 i i+1 i+2 i-2 i i+1 i+2

C O R R E C T A C T IO N
JU M P B A C K W A R D

S te p S te p i -1 S te p S te p S te p S te p S te p i - 1 S te p S te p S te p
i-2 i i+1 i+2 i-2 i k i+2

JU M P F O R W A R D IN T R U S IO N
 S IM P L E C O M P L EX
ERR O R M O D E P HENO T Y P E P H ENO T Y P E

R e p e t it io n R e s ta rt

A c t io n in
w r o n g p la c e R e ve rs a l
J u m p in g

O m is s io n

U n d e rs h o o t
A c tio n a t
w r o n g tim e D e la y

P re m a tu r e
a c t io n

A c t io n o f
R e p la c e m e n t
w ro n g ty p e

S id e -
In s e r t io n
t r a c k in g
A c t io n n o t
in c lu d e d in C a p tu re
c u r r e n t p la n s

In t r u s io n B ra n c h in g

Taxonomy of phenotypes
O ve rs h o o t
Reason’s error taxonomy
 Slip and lapse
 Actions deviated from intention
 Inappropriate attention or memory failure
 Rule-based mistake
 Intentional error at rule-base level
 Wrong use of correct rule or wrong rule
 Knowledge-based mistake
 Intentional error at knowledge-base level
 Limited resources, heuristics, and biases
Taxonomy of unsafe acts
Basic Error
Types

Slip Attention Failures

Unintended
Action
Lapse Memory Failures

Unsafe Rule-based
Acts Mistake
Mistake
Knowledge-based
Mistake

Intended Routine Violation

Action
Violation Optimizing Violation

Necessary Violation
Sabotage
Error classification by
generation mechanism

R0 : Is the operation applicable?

R1 : Is the effect of the operation already
achieved in the current situation?
R2 : Does the normative procedure include
the operation?
R3 : Is the effect of the operation achievable
by any operation in the normative
procedure?
Error classification by
generation mechanism
R 0
ye s no

ye s U n n e c e s s a ry
R 1 C 1, C 3 C 1, C 3, C 5
o p e r a tio n
no
O m im is s io n
ye s C 1, C 2 or
R 2 C 2, C 6
C 5, C 6 W ro n g s e q u e n c e
no
M is s - s e le c tio n
R 3 ye s C 1, C 2 w it h
C 2, C 4
C 4, C 5 c o r r e c t in te n tio n

no C 1, C 2
C 2, C 3 W r o n g in te n tio n
C 3, C 5

I n a p p lic a b le E rro r ty p e
o p e r a tio n
Y.Furuhama
Causal factors of error
 Personal factors
 Knowledge and experience, physical disorder
or disease, personal trait, motivation, etc.
 Environmental factors
 Working environment, hardware design, task
design, instruction, training, etc.
 Social (organizational) factors
 Man shift, staffing, role system, job control,
job planning, rules, morale, etc.
Organizational accidents
D e fe n c e s

H a za rd s Losses

U n s a fe
a c ts

L o c a l w o rk s p a c e fa c to rs

O rg a n iz a tio n a l fa c to r s
Key points of human error

 Human error is not the cause of an event,

but a consequence of events.
 Human error has various types, and it
cannot be discussed in general.
 Crucial human error does not occur
accidentally but it occurs inevitably.
Ecological view of human error

Personal factors
Environmental factors
Social factors

Context Cognitive
Mechanisms
HEP  P(unsafe act | context)  P(context)
THERP

 Swain & Guttmann, WASH-1400

 Assumptions
 Human performance can be decomposed into
elementary steps of actions.
 The basic human error rate of each step is m
ainly depends on its error mode.
 The reliability of human performance can be a
ggregated from the basic error rates.
Procedure of THERP
1. Collection of relevant information
2. Task decomposition into elementary steps
3. Generation of event tree
4. Assignment of basic error rate by error mode
5. Assessment of Performance Shaping Factors
6. Assessment of dependencies between steps
7. Evaluation of total human error probability
8. Adjustment for recovery effects
9. Sensitivity analysis (if necessary)
 a = .99992 A = .00008

Event tree b = .99

F1
B = .01

c = .99985 C = .00015

F2
d = .9984 D = .0016

F3
e = .9984 E = .0016

g = .99999 G = .00001

F4
h = .9984 H = .0016

g = .99999 G = .00001

F5
K = .9999 K = .0001
HEP = A+BC+D+EG+HG+K = 0.0018
S F6
Error mode of THERP

 Omission : lack of an expected action

 Commission : improper action execution
 Unnecessary action
 Wrong order of action sequence
 Improper timing
 Wrong object or direction
 Improper intensity or duration
Dependency model of THERP

dependency
P (succ i | succ i-1) P (fail i | fail i-1)
level
ZD BHSP BHFP
LD (1+19BHSP) / 20 (1+19BHFP) / 20
MD (1+6BHSP) / 7 (1+6BHFP) / 7
HD (1+BHSP) / 2 (1+BHFP) / 2
CD 1 1
BHSP : BeforeHand Success Probability
BHFP : BeforeHand Failure Probability
Performance Shaping Factor (PSF)

External PSF Internal PSF

Situation Task and tools • training
• structure • perception • experience
• environment • motion • skill
• work period • compatibility • personality
• work shift • prediction • intelligence
…… …… • motivation
Stressor • mentality
Mental Physiological ……
• abruptness • duration
• duration • fatigue
• work speed • discomfort
• workload • hunger, thirst
…… ……
OAT

 Hall & Fragola

 Assumptions
 Human performance consists of three phases:
information perception, decision making, and
action execution.
 The reliability of decision making depends on
the available time for thinking.
Procedure of OAT

1. Identification of relevant human performance an

d necessary information to decide.
2. Assessment of the available time for thinking
tT = T0 - tI - tA
3. Assessment of error rate from Time Reliability Co
rrelation (TRC) data.
4. Assessment of system reliability by Event Tree an
d Fault Tree analyses.
Time Reliability Correlation

100 

50
R e s p o n s e T im e ( s e c )


 
 

10 

 
5
 1  (ln t   ) 2 

 f (t )  exp  
2 t  2 2

 

1
5 25 50 75 95
C u m u la t i v e R e s p o n s e P r o b a b i li t y ( % )
SLIM-MAUD

 Embrey
 Assumptions
 Human error probability is a function of Perfor
mance Shaping Factors.
 Total effects of different PSFs can be aggrega
ted by the Multiple Attribute Utility Decomposi
tion.
Procedure of SLIM-MAUD

1. Selection of relevant PSFs for task

2. Assessment of weighting factor of each PSF by
expert judgement
3. Scoring of each PSF by expert judgement
4. Calculation of Success Likelihood Index (SLI)
5. Evaluation of human error probability using em
pirical base point data
6. Assessment of confidence interval of outcome
Calculation of SLI
PSF Importance Weight
Quality of information 100 0.50
Training 50 0.25
Available time 30 0.15
Procedure 20 0.10
Total 200 1.00

PSF Weight PSF score weight×score

Quality of information 0.50 70 35.0
Training 0.25 20 5.0
Available time 0.15 10 1.5
Procedure 0.10 50 5.0
Total 46.5
Evaluation of HEP from SLI

log HEP Empirical Data Points

log P = a · SLI + b

34.5
Success Likelihood Index
Trend of HRA

 Reliability of HRA is low.

 JRC benchmark (15 teams)
 The results disagreed by more than an order.
 1st-generation HRA
 ignores cognitive mechanisms and error of co
mmission, i.e., too behavioristic
 2nd-generation HRA
 ATHEANA, CREAM, MERMOS