Human Error

Oleh:
Edwina Rudyarti
Human Error adalah suatu keputusan atau tindakan
manusia yang tidak diinginkan yang berdampak pada
penurunan keefektifan bekerja, sistem dan safety
Error dapat terjadi pada operator dan desain pekerjaan
 Examples

www.baddesigns.com
Facts about Human Error
It thrives in every industry
It is a major contributor to events and unwanted
outcomes
It is costly, adverse to safety and hinders
productivity
The greatest cause of human error is weaknesses in
the organization, not lack of skill or knowledge
Error rates can never be reduced to zero
Consequences of errors can be eliminated
Human Error adalah faktor utama dari terjadinya
kecelakaan
Sesuai teori swiss cheese (rasmussen)
Pendekatan dalam human error:
 Behavioral approach
 Work situation approach (dibawah kendali
manajemen)
 General work situation
 Cognitive features (decision making)
 Organizational feature
 Causes of system crashes Other
100%
90% 18%
% of System Crashes

80%
System
70% management
60%
50% 53%
40% Software
30%
failure
20%
18%
10%
10% Hardware
0%
failure
1985
Time (1985-1993) 1993
 9%
22%

Human-co.
Human-ext.
5% Hardware Failure
Software Failure
Overload
47%
Vandalism
17%
 Error Precursors
short list
Task Demands
• Time pressure (in a hurry)
• High Workload (memory requirements)
• Simultaneous, multiple tasks
• Repetitive actions, monotonous
• Irrecoverable acts
• Interpretation requirements
• Unclear goals, roles, & responsibilities
• Lack of or unclear standards
Work Environment
• Distractions / Interruptions
• Changes / Departures from routine
• Confusing displays or controls
• Workarounds / OOS instruments
• Hidden system response
• Unexpected equipment conditions
• Lack of alternative indication
• Personality conflicts
Individual Capabilities
• Unfamiliarity w/ task / First time
• Lack of knowledge (mental model)
• New technique not used before
• Imprecise communication habits
• Lack of proficiency / Inexperience
• Indistinct problem-solving skills
• “Hazardous” attitude for critical task
• Illness / Fatigue
Human Nature
• Stress (limits attention)
• Habit patterns
• Assumptions (inaccurate mental picture)
• Complacency / Overconfidence
• Mindset (“tuned” to see)
• Inaccurate risk perception (Pollyanna)
• Mental shortcuts (biases)
• Limited short-term memory
Human Error
Stages of Human Decision-making at which
Human Error can Occur:

1. Activation/detection of system state signal

2. Observation and data collection
3. Identification of system state
4. Interpretation of situation
5. Definition of objectives
6. Evaluation of alternative strategies
7. Procedure selection
8. Procedure execution
 Information Processing Model
Wickens et al. 2004

Attention Resources

Response Response
Perception
Registration

Selection Execution
Sensory

Decision
Making
Working
Memory

Long-Term Memory

Perceptual Encoding Central Processing Responding

 Human Information
Processing

Shared
Attention
Resources

Sensing
Sensing Thinking
Thinking Acting
Acting

Information
Source: Wickens, 1992
Flow Path
 Human Error Taxonomy
Reason (1992)
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
 A theory of human error
(distilled from J. Reason, Human Error, 1990)

• Preliminaries: the three stages of cognitive

processing for tasks
1) planning
• a goal is identified and a sequence of actions is
selected to reach the goal
2) storage
• the selected plan is stored in memory until it is
appropriate to carry it out
3) execution
• the plan is implemented by the process of carrying out
the actions specified by the plan
 A theory of human error (2)
• Each cognitive stage has an associated form of error
– slips: execution stage
• incorrect execution of a planned action
• example: miskeyed command
– lapses: storage stage
• incorrect omission of a stored, planned action
• examples: skipping a step on a checklist, forgetting to
restore normal valve settings after maintenance
– mistakes: planning stage
• the plan is not suitable for achieving the desired goal
• example: TMI operators prematurely disabling HPI pumps
 Origins of error: the GEMS
model
• GEMS: Generic Error-Modeling System
– an attempt to understand the origins of human error
• GEMS identifies three levels of cognitive task processing
– skill-based: familiar, automatic procedural tasks
• usually low-level, like knowing to type “ls” to list files
– rule-based: tasks approached by pattern-matching from a set
of internal problem-solving rules
• “observed symptoms X mean system is in state Y”
• “if system state is Y, I should probably do Z to fix it”
– knowledge-based: tasks approached by reasoning from first
principles
• when rules and experience don’t apply
 GEMS and errors
• Errors can occur at each level
– skill-based: slips and lapses
• usually errors of inattention or misplaced attention
– rule-based: mistakes
• usually a result of picking an inappropriate rule
• caused by misconstrued view of state, over-zealous pattern
matching, frequency gambling, deficient rules
– knowledge-based: mistakes
• due to incomplete/inaccurate understanding of system,
confirmation bias, overconfidence, cognitive strain, ...
• Errors can result from operating at wrong level
– humans are reluctant to move from RB to KB level even if
rules aren’t working
 Error frequencies
• In raw frequencies, SB >> RB > KB
– 61% of errors are at skill-based level
– 27% of errors are at rule-based level
– 11% of errors are at knowledge-based level
• But if we look at opportunities for error, the order
reverses
– humans perform vastly more SB tasks than RB, and
vastly more RB than KB
• so a given KB task is more likely to result in error than a
given RB or SB task
 Error Mechanism Categories
Basic Errors

Skill Based: Attention Failures

Memory Failures
Failures in Execution

Perceptual Based: Visual

Auditory
Tactile
Decision Errors

Rule Based: Misapplication of a good rule

Application of a bad rule

Knowledge Based: Inaccurate knowledge of the system

Incomplete knowledge of the system
Attentional Failures
• Intrusion – entering a dangerous area / location

 Commission – performing an act incorrectly

 Omission – failure to due something

 Reversal – trying to stop or undo a task already

initiated

 Misordering – task or set of task performed in the

wrong sequence

 Mistiming – person fails to perform the action within

theltime allotted
Memory Failures
Losing ones place; forgetting intentions

Rule-based Based Mistakes

Application of a bad rule
“I’m in a public space in view of many people, therefore I
won’t be robbed.”

Misapplication of a good rule

“A patient on chronic medication became concerned about
addiction and therefore deliberately stop taking the drug for
a period each year even though the drug in question was
not addictive.”
Contributing Factors
Contributing Factors in Accident Causation (CFAC)
Sanders and Shaw (1988)

1. Management (organization/policies)

2. Environment (physical conditions)

3. Equipment (design)

4. Work (task characteristics)

5. Social/psychological environment (culture)

6. Worker/coworkers (personal attributes)

Typical Errors
Associated with new technologies or systems

Mode Error – user thought system was in one mode when it

was actually in another.
Getting Lost – Users get lost in display architectures.
Difficulty in finding the right screen or data set.
Not Coordinating Data Entries – poor coordination between
multiple users inputting data into the same system.
Overload – system use drains attention resources from other
equally important tasks.
Data Overload –users forced to sort through a large amount
of data produced by the system in order to determine the true
nature of the situation.
Not Noticing Changes – digital displays used to
communicate system changes or trends.
Automation Surprises – system automation did something
user did not expect or anticipate.
Techniques & Methods
For Human Error Identification

 Technique for human error rate prediction (THERP)

 Hazard and operability study (HAZOP)
 Skill, rule and knowledge model (SKR)
 Systematic human error reduction and prediction
approach(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)
 Performance Modes--Attending Problems
High Kn Inaccurate
o wl
ed Mental Picture
Pa
t t e ge - B
rns as
ed
Ru
Attention (to task)

le
B as
If - ed
Th
Misinterpretation en

Source: James Reason. Managing the Risks

Sk
ill-

of Organizational Accidents, 1998.

as B
Au ed
to
Inattention

Low

Low Familiarity (w/ task) High

Pencegahan Human Error
Mengurangi frekuensi
Meningkatkan jam terbang
Meningkatkan kemampuan pemulihan/penganan
terhadap keadaan human error
Mengurangi risiko
 Assessment
Kuantitatif
of Human Error
Pertama, analisis pekerjaan (task analysis)
Technique for human error rate prediction (THERP)
Kedua, Analisis Proses Operasi
Klasifikasi pekerjaan di proses operasi:
o Simple tasks: pekerjaan rutin
o Vigilance tasks
o Emergency behaviour
o Complex tasks: pek tdk rutin tetapi membutuhkan ketepatan
dalam pengambilan keputusan
o Control tasks: proses pengawasan
Goal Directed Activity (GDA)
Success Likelihood Index Method (SLIM)
Human Error Assessment and Reduction Technique (HEART)