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Human Error, Part 2: Deliberate Violations, 3.0) Building robustness to…

- - - - e.g. occurs when a person is doing repairs and another person unknowingly turns the circuit on
    - - results in cutting of skin, shearing, crushing, breaking, or straining
    - - difficult to use
      - poorly designed
      - cumulative trauma
    - - irritants
      - systemic poison
      - asphyxiants
      - carcinogens
- - - - incorrect omission of a stored, planned action
      - etc: skipping a step on a checklist, forgetting to restore normal valve settings after maintenance
    - - the plan is not suitable for achieving the desired goal
      - etc: TMI operators prematurely disabling HPI pumps
    - - etc: miskeyed command
      - incorrect execution of a planned action
- - - - Rule-based Mistakes
      - Memory-lapse mistakes
      - Knowledge-based mistakes
  - - - Action-based – wrong action is performed
        
        etc: pay considerable attention to do tasks
      - Memory-lapse – memory fails, intended action not done or results not evaluated
        
        etc: Forget to turn off iron after ironing
    - - often result from a lack of attention to the task
        
        Novice
        
        pay considerable attention to do tasks
        
        Experts
        
        perform tasks automatically, subconscious
      - Three most relevant to design
        
        Capture slips
        
        Description-similarity slips
        
        Mode error
  - - - humans are inherently fallible and errors are inevitable
      - hard-to-detect latent errors can be more troublesome than front-line errors
      - human psychology must not be ignored
  - - - operators don’t get hands-on control experience
      - decreases system visibility and increases complexity
      - rule-set for RB tasks and models for KB tasks are weak
    - - harder to detect/tolerate/fix design errors