HUMAN ERROR

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Ülger Ahmet

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HUMAN ERROR José Luis Garc í a-Chico (jgarciac@email.sjsu.edu) San Jose State University ISE 105 Spring 2006 April 24, 2006 “ To err is human…” (Cicero, I century BC) “… to understand the reasons why humans err is science” (Hollnagel, 1993)

What is important to know about human error? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Human error in nuclear powers plants ,[object Object],[object Object],[object Object],[object Object]

Definition of Human Error ,[object Object],[object Object],[object Object]

Human error taxonomies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Human error taxonomies: SRK model of behavior (Rasmussen, 1982) ,[object Object],[object Object],[object Object],[object Object]

Generic Error Modeling System-GEMS (Reason, 1990) Skill-based level

Human Error Distribution ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Human are error prone, but….is that all? ,[object Object],[object Object],[object Object],[object Object]

Model of Human Error causation (Reason, 1990) Accident / mishap Adapted from Shappel (2000)

Building solutions ,[object Object],[object Object],[object Object],[object Object]

Learning from past accident/incident ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Nine steps to move forward from error: Woods & Cook (2002) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

A cased study: HUMAN FACTOR ANALYSIS OF OPERATIONAL ERRORS IN AIR TRAFFIC CONTROL Jose Luis Garcia-Chico San Jose State University Master Thesis of Human Factors and Ergonomics

Motivation of the study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Overview | Method | Research Questions | Initial Results

Taxonomic study: Initial Results Overview | Method | Research Questions | Initial Results

Top-10 OEs Overview | Method | Research Questions | Initial Results

Concurrent and contextual factors Overview | Method | Research Questions | Initial Results

Further Reading ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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HUMAN ERROR

1. HUMAN ERROR José Luis Garc í a-Chico (jgarciac@email.sjsu.edu) San Jose State University ISE 105 Spring 2006 April 24, 2006 “ To err is human…” (Cicero, I century BC) “… to understand the reasons why humans err is science” (Hollnagel, 1993)

6. Human error performance (Norman, 1983)

9. Error distinctions

10. Generic Error Modeling System-GEMS (Reason, 1990) Skill-based level

11.

12.

13. Model of Human Error causation (Reason, 1990) Accident / mishap Adapted from Shappel (2000)

14.

15.

16.

17. A cased study: HUMAN FACTOR ANALYSIS OF OPERATIONAL ERRORS IN AIR TRAFFIC CONTROL Jose Luis Garcia-Chico San Jose State University Master Thesis of Human Factors and Ergonomics

18.

19. Taxonomic study: Initial Results Overview | Method | Research Questions | Initial Results

20. Top-10 OEs Overview | Method | Research Questions | Initial Results

21. Proximity of encounters: OE output

22. Concurrent and contextual factors Overview | Method | Research Questions | Initial Results

23. Taxonomic study: Initial Results Overview | Method | Research Questions | Initial Results

24. Proximity in EOs

25. Co-occurrence of OE

26. D-side presence/absence

27. Time on Position

28.