현대의 고도화, 자동화된 시스템이 파생한 휴먼에러에 관한 이론적 고찰을 통한 리스크 대응전략 설정

Abstract

This paper provides an integrated view on human and system interaction in advanced and automated systems, which adopting computerized multi-functional artifacts and complicated organizations, such as nuclear power plants, chemical plants, steel and semi-conduct manufacturing system. As current systems have advanced with various automated equipments but human operators from various organizations are involved in the systems, system safety still remains uncertain. Especially, a human operator plays an important role at the time of critical conditions that can lead to catastrophic accidents. The knowledge on human error helps a risk manager as well as a designer to create and control a more credible system. Several human error theories were reviewed and adopted for forming the integrated perspective: gulf of execution and evaluation; risk homeostasis; the ironies of automation; trust in automation; design affordance; distributed cognition; situation awareness; and plan delegation theory. The integrated perspective embraces human error theories within three levels of human-system interactions such as affordance level, psychological logic level and trust level. This paper argued that risk management process should dealt with human errors by providing (1) reasoning improvement; (2) support to situation awareness of operators; and (3) continuous monitoring on harmonization of human system interaction. This approach may help people to understand risk of human-system interaction failure characteristics and their countermeasures.