ENGR. YOSHIKI B. KURATA, CIE, AAE, MSc.

IE, CLSSGB
Course Instructor
CONTENTS

Origins and Development

History of Human Factors &

Ergonomics

Human Error Analysis

Human Information Processing

HUMAN ERROR ANALYSIS
HUMAN ERROR

❑ An (in) action that was not intended.

❑ An action not desired by a set of rules or an external observer.

❑ An action that led the task or system outside its acceptable limits.
HUMAN ERROR

Goal of Human Error in Ergonomics

Minimize human errors to maximize system performance.
How does Human Error occur?
✓ Task Complexity
✓ Error-likely Situations
✓ Individual Differences
Error Detection
✓ Action Based
✓ Output Based
✓ Process Based
HUMAN ERROR PROBABILITY

The ratio of errors made with respect to the number of

opportunities for error

𝑷 𝑬𝒓𝒓𝒐𝒓 = 𝟏 − 𝑯𝒖𝒎𝒂𝒏 𝑹𝒆𝒍𝒊𝒂𝒃𝒊𝒍𝒊𝒕𝒚

What is a
Human
Reliability?
HUMAN RELIABILITY

❑ The number of errors and number of opportunities for error.

Estimating Human Reliability
❑ Using Monte Carlo Simulation
▪ Describe the task
▪ Setup a simulation of the operator being observed
▪ Repeat many times as possible (may use the work sampling
technique to determine the optimal number of observations)
▪ Estimate the human reliability
Goal of Human Reliability
The goal of human reliability analyses is to apply the same principles to the
human operator that we apply to the machine or device to prevent error that
may lead to system failure.
HUMAN ERROR CAUSES

❑ Design Deficiency - when the mechanical, electrical or other components

of the design has a problem that caused the mishap;

❑ Equipment Malfunction - when the machine operated incorrectly;

❑ Manufacturing Defect - when the material or assembly has an issue that

causes it to fail;

❑ Environmental Hazard - when an outside factor such as the weather

causes the hazardous condition

❑ Human Error - when a person did something wrong

HUMAN ERROR EXAMPLES

❑ Failing to perform or omitting a task

❑ Performing the task incorrectly

❑ Performing an extra or non-required task

❑ Performing tasks out of sequence

❑ Failing to perform the task within the time limit associated with it

❑ Failing to respond adequately to a contingency

HUMAN ERROR CONTRIBUTORS

❑ Population stereotype
❑ Performance requirements that exceed human capability
❑ Design that promotes fatigue
❑ Inadequate facilities or information
❑ Difficult tasks
❑ Dangerous tasks
❑ Unpleasant tasks
❑ Repetitive or boring tasks
❑ Tasks at odds with the person's aptitude
❑ Stress, Illness, Sleep Deprivation, Injury
HUMAN ERROR RATE PREDICTION

Identify potential Estimate error

Describe the system
errors likelihood

Estimate error
Determine relevant
consequences
parameters and
moderating factors

Combine error Predict task/system

probabilities success probability
HUMAN ERROR TAXONOMY
Basic Errors

Attentional
Slip Failures

Unintended
Action

Memory
Lapse Failures
Unsafe
Acts
Rule-based or
Mistake Knowledge-based
Mistakes
Intended
Action
Routine violations
Violation Exceptional violations
Sabotage
According to Reason (1992)
STOCHASTIC METHOD

Will Determine:

❑ Completion of task in the allotted time

❑ Work overload
❑ Operator efficiency

Includes the following parameters:

❑ Mean times for each subtask

❑ Variability of a representative operator
❑ Urgency and stress conditions
❑ Probability of correct performance of the subtask
RISK ANALYSIS

❑ Concerned with the measurement of possible consequences that

accompany specific failures (e.g. monetary loss, loss of life)

❑ Emphasis is primarily on the influence of system failures on the

environment.
TECHNIQUES & METHODS

❑ Technique for Human Error Rate Prediction (THERP)

❑ Hazard and Operability Study (HAZOP)
❑ Skill, Rule and Knowledge Model (SKR)
❑ Systematic Human Error Reduction and Prediction (SHERPA)
❑ Generic Error Modeling System (GEMS)
❑ Potential Human Error Cause Analysis (PHECA)
❑ Murphy Diagrams
❑ Critical Action and Decision Approach (CADA)
❑ Human Reliability Management System (HRMS)
❑ Influence modeling and assessment system (IMAS)
❑ Confusion Matrices
❑ Cognitive Environment Simulation (CES)
MURPHY DIAGRAMS

Diagrammatic representations of error modes that illustrate the underlying

causes associated with cognitive decision making tasks.
1. Activity • activation/detection of system state signal
• observation and data collection
• identification of system state
• interpretation of situation
• definition of objectives
• evaluation of alternative strategies
• procedure selection
• procedure execution
2.Outcome
3.Proximal Sources
4.Distal Sources
MURPHY DIAGRAMS
APPROACHES TO MINIMIZE H.E.

1. Personnel Selection

Appropriate skills and capabilities to perform required tasks.

2. Training

Helps ensure appropriate skills; can be expensive and time consuming;

people may revert to original behaviors under stress

3. Design

Preferred method; maintainability, displays & controls, feedback (error

detection), user expectations; categories: exclusionary, preventative, and
fail-safe