Inhoudsopgave
College 1: Introduction & error classification...................................................2
College 2: Old (person), and new (system) view...............................................6
College 3: Attention.....................................................................................11
College 4: Eyewitnesses...............................................................................20
College 5: Errors and mistakes in medicine....................................................25
,Human Error
College 1: Introduction & error classification
What is human error? You do something wrong, or you forget to do something.
We as humans make mistakes and do things wrong.
Error = The failure of planned actions to achieve their desired goal without some
unforeseen or chance intervention. We plan something, and it does not go that
way. But not always something you have control over.
Error types (taxonomy)
1. Errors of automation (you are not aware of it until it goes wrong)
Slips (attention failure)
Lapses (memory failure)
Fumbles (physical)
2. Errors of conscious control (people have a plan, they are aware of it)
Mistakes (intention failure)
Violations (people are doing something illegal, they have a reason to do
that)
Rasmussen – human performance
Skill level performance
We tend to perform on this level, because this is efficient. This is the easiest
performance level of the three levels. The moment we gain experience, we
automate more. An example of skill level performance are the children playing
the guitar. They do not have sheet music anymore, they don’t think about this.
Also, the stroop test (naming the color of the word) is an example of a skill level
test. Skill level is crucial. Largest part of behavior is skill level.
Rule level performance
Pattern matching and recognition. But these are not official rules, but how we
learn it. If things go wrong on this level, the consequences are a lot bigger than
when something goes wrong on the skill level.
Knowledge level
Bounded rationality and thinking. Problem solving is a big aspect here. A problem
here could be thinking about what comes after the year 1 BC. We think it is the
year 0, but it actually is 1 AD.
, Skill based errors
(slips and lapses)
typically proceed
detection of a
problem.
Rule- and knowledge-
based mistakes typically follow detection of a problem.
Classification
Oyster Creek Nuclear Power Plant (1979): An operator inadvertently
pressed the wrong two buttons on the control panel and failed to realise
slip.
Ginna Nuclear Power Plant (1982): Operators used the wrong strategy
when operating the pressure release valve, cycling it open too often. As a
result, it was stuck open knowledge based mistake.
Three Mile Island (1979): Operators did not realise that the relief valve on
the pressurizer was stuck open. The panel display indicated it was closed.
Which they took to mean it was really shut rule based mistake.
Skill level errors
Inattention/ omission errors.
Double-capture slips (distracter captures executive control. Stronger
automation takes over. You forget to do something special)
Omissions following interruption (attentional check fails after an external
event. Normal behavior is interrupted)
Delay reduces control (detached intentions/ environmental capture/
multiple sidesteps)
Perceptual confusions (a pattern matching problem. Looking similar, thus
inclined to act that way)
Interference errors (a control issue/ blends / spoonerism. Automated
behavior that comes back)
Overattention (omissions/ repetitions/ reversals. Stuff where paying too
much attention is not a good idea).
Perceptual confusion on skill level can have serious consequences. Like the error
of the taser gun and the actual gun. The officer in the video did not feel and see
the difference and shot the person instead of tasering him.
Rule level errors
Misapplication of good rules and application of bad rules. If this than that.
Misapplication of good rules
First exceptions (over-generalization. The first time an exception is met.
Leads to the creation of sub-rules).
Countersigns and nosigns. Three kinds of information:
1. Signs: all or some of the conditional aspects of the rule met.
2. Countersigns: indicate another rule is appropriate.
3. Nosigns: do not relate to any existing rule and are simply noise in
the system.
College 1: Introduction & error classification...................................................2
College 2: Old (person), and new (system) view...............................................6
College 3: Attention.....................................................................................11
College 4: Eyewitnesses...............................................................................20
College 5: Errors and mistakes in medicine....................................................25
,Human Error
College 1: Introduction & error classification
What is human error? You do something wrong, or you forget to do something.
We as humans make mistakes and do things wrong.
Error = The failure of planned actions to achieve their desired goal without some
unforeseen or chance intervention. We plan something, and it does not go that
way. But not always something you have control over.
Error types (taxonomy)
1. Errors of automation (you are not aware of it until it goes wrong)
Slips (attention failure)
Lapses (memory failure)
Fumbles (physical)
2. Errors of conscious control (people have a plan, they are aware of it)
Mistakes (intention failure)
Violations (people are doing something illegal, they have a reason to do
that)
Rasmussen – human performance
Skill level performance
We tend to perform on this level, because this is efficient. This is the easiest
performance level of the three levels. The moment we gain experience, we
automate more. An example of skill level performance are the children playing
the guitar. They do not have sheet music anymore, they don’t think about this.
Also, the stroop test (naming the color of the word) is an example of a skill level
test. Skill level is crucial. Largest part of behavior is skill level.
Rule level performance
Pattern matching and recognition. But these are not official rules, but how we
learn it. If things go wrong on this level, the consequences are a lot bigger than
when something goes wrong on the skill level.
Knowledge level
Bounded rationality and thinking. Problem solving is a big aspect here. A problem
here could be thinking about what comes after the year 1 BC. We think it is the
year 0, but it actually is 1 AD.
, Skill based errors
(slips and lapses)
typically proceed
detection of a
problem.
Rule- and knowledge-
based mistakes typically follow detection of a problem.
Classification
Oyster Creek Nuclear Power Plant (1979): An operator inadvertently
pressed the wrong two buttons on the control panel and failed to realise
slip.
Ginna Nuclear Power Plant (1982): Operators used the wrong strategy
when operating the pressure release valve, cycling it open too often. As a
result, it was stuck open knowledge based mistake.
Three Mile Island (1979): Operators did not realise that the relief valve on
the pressurizer was stuck open. The panel display indicated it was closed.
Which they took to mean it was really shut rule based mistake.
Skill level errors
Inattention/ omission errors.
Double-capture slips (distracter captures executive control. Stronger
automation takes over. You forget to do something special)
Omissions following interruption (attentional check fails after an external
event. Normal behavior is interrupted)
Delay reduces control (detached intentions/ environmental capture/
multiple sidesteps)
Perceptual confusions (a pattern matching problem. Looking similar, thus
inclined to act that way)
Interference errors (a control issue/ blends / spoonerism. Automated
behavior that comes back)
Overattention (omissions/ repetitions/ reversals. Stuff where paying too
much attention is not a good idea).
Perceptual confusion on skill level can have serious consequences. Like the error
of the taser gun and the actual gun. The officer in the video did not feel and see
the difference and shot the person instead of tasering him.
Rule level errors
Misapplication of good rules and application of bad rules. If this than that.
Misapplication of good rules
First exceptions (over-generalization. The first time an exception is met.
Leads to the creation of sub-rules).
Countersigns and nosigns. Three kinds of information:
1. Signs: all or some of the conditional aspects of the rule met.
2. Countersigns: indicate another rule is appropriate.
3. Nosigns: do not relate to any existing rule and are simply noise in
the system.
