Types Of Human Errors Research Articles

디지털 기기 기반 직무 수행 시 인적오류위험성에 대한 실험적 평가

The application of advanced Main Control Room(MCR) is accompanied with lots of changes and different forms and features through the virtue of new digital technologies. The characteristics of these digital technologies and devices give many opportunities to the interface management, and can be integrated into a compact single workstation in advanced MCR so that workers can operate the plant with minimum physical burden under any operation conditions. However, these devices may introduce new types of human errors and thus a means to evaluate and prevent such errors is needed, especially those related to characteristics of digital devices. This paper reviewed the new type of human error hazards of tasks based on digital devices and surveyed researches on physiological assessment related to human error. An experiment was performed to verify human error hazards by physiological responses such as EEG which was measured to evaluate the cognitive workload of operators. And also, the performances of four tasks which are representative in human error hazard tasks based on digital devices were compared. Response time, <TEX>${\beta}$</TEX> power spectrum rate of each task by EEG, and mental workload by NASA-TLX were evaluated. In the results of the experiment, the rate of the <TEX>${\beta}$</TEX> power was increased in the task 1 and task 4 which are searching and navigating task and memory task of hierarchical information, respectively. In case of the mental workload, in most of evaluation items, task 1 and 4 were highly rated comparatively. In this paper, human error hazards might be identified by highly cognitive workload. Conclusively, it was concluded that the predictive method which is utilized in this paper and an experimental verification can be used to ensure the safety when applying the digital devices in Nuclear Power Plants (NPPs).

Runway Excursion: A Problem

Landing and takeoff overruns, undershoots, and veer-offs account for most of the accidents that occur on or in the immediate vicinity of the runway. Accident statistics show that, from 1959 to 2009, 55% of the world's jet fatal aircraft accidents occurred during landing and takeoff phases of the flight and accounted for 51% of all onboard fatalities (Boeing 2010). Although in many cases the causal factors involve some type of human error, the conditions at the airport may contribute significantly to the probability and severity of the accidents.

Application of human error theories for the process improvement of Requirements Engineering

Problems with the structuring and execution of the Requirements Engineering (RE) process can lead to project failure. As the involved activities are essentially human and subjective, the importance of the human factor must be considered. The possible correlation between human errors and the problems that may occur in the RE process is explored in this paper in order to propose a process improvement approach, which applies the theories of human error to build an expert system for automated diagnosis of problems. This approach starts by assessing the importance of individual types of human errors in different contexts using questionnaires to extract knowledge from RE practitioners. A method for managing the priorities of solutions to improve a given process is then proposed and a prototype application is implemented for evaluation with practitioners. The activities with RE practitioners also provide data that are used to construct and evaluate estimators of the presence of human errors and the affected phases of the RE process. Most of the volunteering participants agree that knowledge of error typologies may help to improve their processes to avoid problems.

Human Error Identification based on EEG Analysis for the Introduction of Digital Devices in Nuclear Power Plants

Objective: This paper describes an analysis of electroencephalography(EEG) signals to identify human errors during using digital devices in nuclear power plants(NPPs). Background: The application of an advanced main control room(MCR) has accompanied with lots of changes in different forms and features by virtue of new digital technologies. The characteristics of these digital technologies and devices provide several opportunities for the use of interface management. It can integrate into a compact single workstation in an advanced MCR, allowing workers to operate the plant with minimum physical burden under any operating condition. However these devices may introduce new types of human errors, and thus we need a means to assess and prevent such errors especially those related to digital devices. Method/Conclusion: The EEG data are relatively objective, and thus we introduce several measures to EEG analysis for obtaining the feasibility of human error identification. Application: This study may support to ensure the safety when applying digital devices in NPPs.

A Study on a Trend of Human Error Types Observed in a Simulated Computerized Nuclear Power Plant Control Room

Objective: The aim of this study is to investigate a trend of human error types observed in a series of verification and validation experiments for an Advanced Control Room(ACR) equipped with Lager Display Panel(LDP), Work Station Flat Panel Display(WS FPD), list type Alarm System(AS), Soft Control(SC) and Computerized Procedure System(CPS). Background: Operator behaviors in a fully computerized control room are quite different from those in a traditional hard-wired control room. Operators in an ACR all together monitor plant status and variables through their own interface system such as LDP and WS FPD, are notified of abnormal plant status through their own list type AS, control the plant through their own SC, and follow the structured procedure through their own CPS whereas operators in a traditional control room only separately do their duty directed by their supervisor. Especially the secondary task such as manipulating the user interface of ACR can be an extra burden to all the operators including the supervisor. Method: The Reason"s human error classification method was applied to operators" behavioral data collected from a series of verification and validation experiments where operators showed their plant operational behaviors under a couple of harsh scenarios using the ACR simulator. Results: As operators accustomed to the new ACR system, knowledge or rule based mistakes appearing frequently in the early series of experiments decreased drastically in the latest stage of the series. Slip and lapse types of errors were observed throughout the series of experiments. Conclusion: Education and training can be one of the most important factors for the operators accustomed to the traditional control room to be adapted to the new system and to run the ACR successfully. Application: The results of this study implied that knowledge or rule based mistakes can be reduced by training and education but that lapse type errors might be reduced only through innovative improvement in human-system interface design or teamwork culture design including a new leadership style suitable for ACR.

Development of a quantitative evaluation method for non-technical skills preparedness of operation teams in nuclear power plants to deal with emergency conditions

Many statistical results from safety reports tell that human related errors are the dominant influencing factor on the safe operation of power plants. Fortunately, training operators for the technical and non-technical skills can prevent many types of human errors. In this study, four important non-technical skills in safety critical industries – medical, aviation, and nuclear – were selected to describe behaviors of operation teams in emergency conditions of nuclear power plants (NPPs): communication, leadership, situation awareness, and decision-making skills. Also, preparedness of the non-technical skills was defined, and a quantification method of those skills called NoT-SkiP (Non-Technical Skills Preparedness) was developed to represent ‘how well operation teams are prepared to deal with emergency conditions’ in the non-technical skills aspect by analyzing monitoring-control patterns and a verbal protocol. Two case studies were conducted to validate the method. The first case was applied to Loss of Coolant Accident (LOCA) and Steam Generator Tube Rupture (SGTR) training. Independent variables were scenario, training repetition, and members. Relative values of the NoT-SkiP showed a consistent trend with changing scenarios. However, when training was repeated with the same scenario, NoT-SkiP values of some team were changed. It was supposed that leaders of some teams exerted their knowledge acquired from the previous training and gave up thoroughness of using procedures. When members especially who play a dominant role in teams were changed, values of the NoT-SkiP were significantly changed. Nine teams participated in Interfacing System LOCA (ISLOCA) training; six teams failed to complete the given task, and three teams succeeded. The comparison of NoT-SkiP values of ISLOCA case with Operator Performance Assessment System (OPAS), which mainly check operators’ knowledge and the technical skills, developed by OECD Halden Reactor Project (HRP) gave a plausible reason why teams failed as well as intuitive results on ‘what to be considered in the non-technical skills aspects of teams’ for the next training. The proposed method requires more experiments in order for it to be established on a firm foundation; however, it certainly gives one possible way to supplement existing training strategy in the nuclear industry.

Human performance in control rooms of nuclear power plants: A survey study

AbstractDriven by the increasing demand for reliable and clean energy, the nuclear industry is booming worldwide three decades after the Three Mile Island accident. The transition of technology in nuclear power plants has raised many important human performance issues in every aspect of control systems. To obtain insights on how to meet the challenges imposed by new technologies, a survey was conducted to examine the causal factors of the human–system interface–related human errors in NPP plant control rooms. The survey results can help us identify error categories in terms of the interrelationships among the error causal factors. Moreover, an investigation of the error causal factors can enable us to better understand the nature of the errors and then propose effective corrective action guidelines to mitigate their consequences and enhance human reliability. A five‐factor structure was identified through an exploratory factor analysis: Invisibility of System Status, Incorrect System Interface Design, Insufficient Support for System Diagnosis and Decision Making, Misoperations, and Manual Actions. The five factors are discussed in the context of the decision–action model developed in this study to derive corrective actions for each type of potential human error. © 2011 Wiley Periodicals, Inc.

Air Traffic Volume and Air Traffic Control Human Errors

Navigable airspaces are becoming more crowded with increasing air traffic, and the number of accidents caused by human errors is increasing. The main objective of this paper is to evaluate the relationship between air traffic volume and human error in air traffic control (ATC). First, the paper identifies categories and elements of ATC human error through a review of existing literature, and a study through interviews and surveys of ATC safety experts. And then the paper presents the results of an experiment conducted on 52 air traffic controllers sampled from the Korean ATC organization to find out if there is any relationship between traffic volume and air traffic controller human errors. An analysis of the experiment clearly showed that several types of ATC human error are influenced by traffic volume. We hope that the paper will make its contribution to aviation safety by providing a realistic basis for securing proper manpower and facility in accordance with the level of air traffic volume.

Preventing Accidental Exposures from New External Beam Radiation Therapy Technologies

Lessons from accidental exposures are, therefore, an invaluable resource for revealing vulnerable aspects of the practice of radiotherapy, and for providing guidance for the prevention of future occurrences. These lessons have successfully been applied to avoid catastrophic events with conventional technologies and techniques. Recommendations, for example, include the independent verification of beam calibration and independent calculation of the treatment times and monitor units for external beam radiotherapy, and the monitoring of patients and their clothes immediately after brachytherapy. New technologies are meant to bring substantial improvement to radiation therapy. However, this is often achieved with a considerable increase in complexity, which in turn brings opportunities for new types of human error and problems with equipment. Dissemination of information on these errors or mistakes as soon as it becomes available is crucial in radiation therapy with new technologies. In addition, information on circumstances that almost resulted in serious consequences (near misses) is also important, as the same type of events may occur elsewhere. Sharing information about near-misses is thus a complementary important aspect of prevention. Lessons from retrospective information are provided in Sections 2 and 4 of this report.

A Methodology for Assessing Safety Programs Targeting Human Error in Aviation

There is a need to develop an effective methodology for generating and evaluating intervention strategies that map current and proposed safety programs onto well-established types of human error. Toward these ends, we conducted 2 studies using recommendations from National Transportation Safety Board accident investigations and two joint Federal Aviation Administration and industry working groups. The goal of these studies was to identify the types of interventions commonly recommended by these agencies, as well as to develop a framework for evaluating the potential impact of specific safety initiatives that target human error in aviation. The results suggest there are at least 5 approaches to reducing human errors associated with aviation accidents. However, not all are equally utilized by the agencies whose safety recommendations we evaluated in this study. Therefore, we propose a framework called the Human Factors Intervention Matrix as a potential tool for evaluating current aviation safety programs, as well as generating more comprehensive interventions in the future.

Investigation of the Occurrence of Human Errors in Treatment of Cancer Patients with External Beam Radiotherapy

The main objective of clinical radiotherapy procedures is to deliver accurate doses to cancer patients. However, human errors can occur during the treatment planning and dose delivery that may result in under- or overexposure to the patient. Therefore the aim of the present study was to detect and quantify different types of errors that may occur during radiation treatment at the Nuclear Medicine, Oncology and Radiotherapy Institute (NORI) in Islamabad, Pakistan. In this context, systematic studies were carried out over an 18-month period at NORI, for which 800 patients were selected. Eight different types of human errors were detected and corrected before or during the first five radiation therapy fractions. Errors detected during the dose calculation and patient setup steps were ∼22% and ∼14% of the total incidents, respectively. Wedge/shielding blocks placement and field size settings-related errors were ∼10% and 19%, whereas source-surface distance/source-axis distance settings-related errors were ∼8%. Errors observed during treatment time/monitor unit, gantry/collimator angle settings, and counting fraction were about 7%, 9%, and 11%, respectively. Of the 105 errors detected, 28 were major errors (deviation from the prescribed daily dose ≥5%) and 77 were minor errors. The occurrence of minor and major error rates were 9.6% and 3.5%, respectively.

Some characteristics of drivers having caused traffic accidents

Traffic accidents are caused by road, vehicle and human factors, the latter one causing, either by itself or associated with other factors, more than 90% of car accidents. There are three types of human errors: errors in perception, attention and memory. The study included thirty healthy drivers, aged 28-40, with 500 km driven per a week, who had caused at least one traffic accident, but not being intoxicated by alcohol or drugs during the accident. The same number of controls were included. Both the cases and controls were interviewed. We found no difference regarding the marital status, education, conflicts with family members or problems at work, frequency of using the car, speed and habit of fastening seat belts among car drivers who had caused traffic accidents and those who had not. However, we did find significant differences in the frequency of alcohol consumption in general and before driving. Car drivers who had caused traffic accidents used alcohol regularly in greater percentage than those drivers who had not caused any accident--i.e. not a single control claimed to use alcohol regularly. A statistically significant difference was also recorded in alcohol consumption immediately before driving. Such results had been expected, bearing in mind the influence of alcohol on the time needed by drivers to react in emergency. Alcohol consumption is an important factor causing traffic accidents. Since drivers included in our study did not cause a road accident after consuming alcohol, we have found that alcohol consumption, both regular and just before driving, is an important cause of traffic accidents.

Developing a Methodology for Assessing Safety Programs Targeting Human Error in Aviation

There is a need to develop an effective methodology for generating and evaluating interventions for reducing accidents due to human error. In this study, the Human Factors Intervention Matrix (HFIX) was used to evaluate current/proposed FAA safety programs to determine (1) the types of interventions typically proposed by this organization and (2) the types of human error these safety interventions target. Over 600 FAA safety recommendations were examined and categorized using the HFIX methodology. Results suggest that FAA safety programs primarily employ organizational/administrative, technological/engineering and human/operator-based interventions. Few approaches focus on either task or environmental changes. There is also a bias toward interventions aimed at pilot decision-making, rather than other common problems in aviation such as skill-based errors or violations. Further research is needed to develop HFIX as a tool for generating, rather than just evaluating, safety programs.

Human error driving the development of a checklist for foreign material exclusion in the nuclear industry

AbstractIn this article we describe an approach to develop a checklist for foreign material exclusion. Foreign material is material that should not be part of, or supplied with, the product because it can affect the performance of, for example, nuclear fuel rods of nuclear plants. The research itself was initiated by the presence of different types of human errors. Specifically in the nuclear industry, where there is zero tolerance for errors, work to continuously improve safety and quality is of major importance. Our approach should support such work. As a theoretical base, we have considered team errors as well as individual errors. The suggested practical approach is based on foreign materials that originate in or are introduced into a product or a process. © 2007 Wiley Periodicals, Inc. Hum Factors Man 17: 283–298, 2007.

Formal model of human material-handling tasks for control of manufacturing systems

To achieve an effective integration framework for manufacturing systems, a formal model of a system is highly desired. In spite of significant work on automated manufacturing systems, human operators still play a critical role in virtually every system, especially for material-handling processes. To build a model for control and analysis of a system where a human operator is integrated, a formal functional specification of a human material handler (MH) is presented in a hierarchical framework. Two types of human operational errors associated with material-handling tasks are also classified and discussed. A shop floor control example is provided to illustrate the proposed modeling framework

Human errors and violations in computer and information security: The viewpoint of network administrators and security specialists

This paper describes human errors and violations of end users and network administration in computer and information security. This information is summarized in a conceptual framework for examining the human and organizational factors contributing to computer and information security. This framework includes human error taxonomies to describe the work conditions that contribute adversely to computer and information security, i.e. to security vulnerabilities and breaches. The issue of human error and violation in computer and information security was explored through a series of 16 interviews with network administrators and security specialists. The interviews were audio taped, transcribed, and analyzed by coding specific themes in a node structure. The result is an expanded framework that classifies types of human error and identifies specific human and organizational factors that contribute to computer and information security. Network administrators tended to view errors created by end users as more intentional than unintentional, while errors created by network administrators as more unintentional than intentional. Organizational factors, such as communication, security culture, policy, and organizational structure, were the most frequently cited factors associated with computer and information security.

Tasks for Estimating Human Error Tendency

This study was aimed at developing tasks corresponding to six types of human error, which cause serious railway accidents. Types of human error have been classified by a combination of two dimensions induced by a cognitive human error mechanism. One dimension is deficiency of attention, which includes distraction and saturation of attention factors, the other an activation failure of a procedural schema for action and decision, which includes inactivation of a correct procedural schema, an activated habitual incorrect schema, and activated efficient incorrect schema factors. A psychological task was configured for each of the five factors: a digit recitation task for distraction of attention; a vigilance task for saturation of attention; a prospective memory task for inactivation of correct procedural schema; a Stroop task for activated habitual incorrect schema; and another Stroop task after training involving naming a color as a congruent stimulus task for activated efficient incorrect schema. Six human error tasks were configured incorporating these subordinate tasks.

Integration of task networks and cognitive user models using coloured Petri nets and its application to job design for safety and productivity

Changes of task demands due to unforeseen events and technological changes can cause variations in job design such as modifications to job procedures and task allocation. Failure to adapt to job design variations can lead to human errors that may have severe consequences for system safety. Existing techniques for task modelling cannot adequately model how task networks can be adapted to changing work conditions and task demands. Therefore, there is a need to integrate task networks with cognitive user models that indicate how operators process information, make decisions, or cope with suspended tasks and errors. The work described here presents a tool for integrating task and cognitive models using coloured Petri nets. The cognitive user model comprises two modules of attention management (selective and divided attention), a module of memory management of suspended tasks and a module of work organization. Performance Shaping Factors (e.g., workload, fatigue and mental-tracking load) are calculated at any point in time to take into account the context of work (e.g., competing activities, errors and suspended tasks). Different types of human error can be modelled for rule-based behaviours required in proceduralized work environments. Simulation analysis and formal analysis techniques can be applied to process control tasks to verify job procedures, workload management strategies and task allocation schemes in response to technological changes and unfamiliar events.

Searching for the root causes of maritime casualties

This paper opens by placing our current understanding of human error within a model of accident causation. The philosophical problems of bias and hindsight in accident investigation are discussed and a classification of human error types is presented. Two recent surveys of accident data and three case studies are used to highlight the main concerns in the sources of failure. These concerns are onboard violations, lack of onboard situational awareness, and failures in management practice. The paper provides an overview of how these issues have led to developments in maritime training and research. The first development has been the design of more effective training courses through a better understanding of the nature of the skill requirements of situational awareness. The current training is outlined and other areas of research, which are now being undertaken, are described. The paper concludes with a summary of further research and development needs.

Human modeling and simulation for plant operations

It is widely known that various types of human errors occur in the confused state of a plant operator’s mind under abnormal situations. In order to understand the generation mechanism of these human errors in the circumstances of disturbances and equipment failures, we have developed a cognitive information-processing model incorporating the operator’s physical and mental states. The operator model is installed on a PC and connected to a boiler plant simulator for training through a human–machine interface model that we also developed. Using this simulation environment we examine perceptual error in the monitoring mode and cognitive error in fault diagnosis during malfunctions. The simulation results coincide well qualitatively with observations of actual plant operations and simulator training. This operator model can be used to analyze the generation mechanism of various types of human errors from the viewpoint of cognitive information processing. Accordingly, we can study how to prevent human errors and evaluate the effects of various measures by running simulations.