Introduction Rebecca Grayson

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Introduction - Rebecca Grayson

• Live in SF Bay Area
• Many years in software industry
• Main interest is HCI
• Starting own company
• BS in Computer Science
• Grad work in Medical Informatics
• Grandmother of three!

With grandson Joshua, 5 months
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Human Error Identification

• Evaluation of Techniques
• Barry Kirwan (1998)

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Evaluation Criteria

• Comprehensiveness
• Structuredness
• Mode-based?
• EEM/ PEM/ PSF
• Usefulness (ERA)
• Resource usage
• Experts tool

• Experts required
• Documentability
• Usage in PSA?
• Availability
• Quantifiability?
• Life cycle stage?
• Primary objective

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Evaluation Results
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Evaluation Results

• Comprehensiveness
• Basis for cognitive modeling
• Coverage of error components
• Expert vs novice tool
• Requirement for experts
• Usage in real PSAs
• Life cycle application stage
• Primary objective

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Technique Development Requirements
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Summary Remarks

• Adequacy of HEI tools
• no one tool does it all
• Many techniques not highly structured
• HEI not yet a science
• Longer term development requirements
• Trend towards
• cognitive and EOC error ID
• Team dynamics, communication
• Pick one model and complete it!
• Link EEMs, PEMs and PSFs

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Human Error Identification

• A Framework Approach
• Barry Kirwan (1998)

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Introduction

• Integrated toolkit vs independent tools?
• Multiple independent tools
• Pros coverage of error types, pragmatic,
  available now
• Cons confusing, hard to integrate results, more
  training
• Integrated toolkit
• Pros structured, consistent methods, integrated
  results, coverage of error types
• Cons development required

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Toolkit Capabilities and Attributes

• Error assessment range
• Toolkit philosophy
• Integration and coherence
• Best technique usage
• Resource flexibility
• Computerization
• Comprehensiveness vs exclusivity

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The HERA System

• Human Error and Recovery Assessment
• Scoping the analysis
• Critical task identification
• Task analysis
• Error identification
• Skill and rule-based
• Diagnostic and decision-making
• Errors of commission
• Rule validation
• Teamwork and communication
• Integration issues

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Skill and Rule-based HERA Module
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Scoping Error Analysis

• Nature of the plant
• Role of the operator
• Novelty of plant design
• Life cycle stage
• Part of a PSA/HRA?
• Available resources

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Operational Phase Selection

• Normal operation
• Abnormal operation
• Emergency operation
• Beyond design basis accident
• Maintenance, test and calibration
• Outage/shutdown
• Startup/shutdown
• Other (specific to plant)

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Critical Task Identification

• Some considerations
• Identify hazard potential
• Functional analysis of system
• Identify safety mechanisms
• Review incident history
• Review prior analyses
• Interview personnel
• Review emergency procedures

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Task Analysis

• Initial Task Analysis (ITA)
• Hierarchical Task Analysis (HTA)
• Others which can be useful
• Tabular Task Analysis (TTA)
• Tabular Scenario Analysis (TSA)
• Timeline Analysis (TLA)
• Link Analysis (LA)
• Decision-Action Diagrams (DADs)

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HTA Example
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Error Analysis Checklists

• Mission analysis
• Operations level analysis
• Goals analysis
• Plans analysis
• Error analysis (EEM)
• Performance shaping factors (PSF)
• Psychological error mechanisms (PEM)
• HEIST analysis
• Human error HAZOP

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Example PEMs Analysis
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Example HERA Output Table (PEMs)
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Practical Aspects

• Selection of modules
• Multiple identification of same/similar error
• Resources required
• Expertise required

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Ergonomics and HEA

• HERA overkill for most other domains
• Components could be used for error ID
• Ergonomists need more detail
• Ergonomists use task-independent factors
• HERA offers ID of error reduction mechanisms