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determination of outcome (succeed or fail), and estimation of subjectively available time
(adequate or inadequate). Four additional parameters are number of simultaneous goals,
availability of plans, the event horizon, and the mode of execution. The number of simultaneous
goals parameter refers to whether or not multiple goals are considered or just a single goal is
considered. The availability of plans parameter refers to having pre-defined or pre-existing plans
for which the next action can be chosen. The event horizon parameter is concerned with how
much of the past and future is taken into consideration when a choice of action is made.
Reference to the past is called the history size while reference to the future is called the
prediction length. The mode of execution parameter makes a distinction between subsumed and
explicit actions where a mode of execution can be ballistic/automatic or feedback controlled. The
relationships of how a person can change from one mode to another and the performance
characteristics of each control mode are discussed at length. The purpose of COCOM is to model
cognition in terms of contextual control rather than procedural prototypes.
Hollnagel, E. (1998). Cognitive reliability and error analysis method (CREAM). Alden
Group, Oxford.
Hollnagel introduces a second generation human reliability analysis method. This method has
two requirements. It must use enhanced probabilistic safety assessment event trees and it must go
beyond the categorization of success-failure and omission-commission. The purpose of CREAM
is to offer a practical approach for both performance analysis and prediction and be as simple as
possible. The model is expressed in terms of its functions as opposed to its structure. Four
aspects of the CREAM method are cited as being important. CREAM is bi-directional and
allows retrospective analysis as well as performance prediction. The method is recursive rather
than strictly sequential. There are well-defined conditions that indicate when an analysis or a
prediction is at an end. And finally, the model is based on the distinction between competence
and control which offers a way of describing how performance depends on context. CREAM
uses classification groups as opposed to a hierarchical classification scheme. This classification
scheme separates causes (genotypes) from manifestations (phenotypes). Also, CREAM relies on
the Contextual Control Model (COCOM) of cognition which is an alternative to information
processing models.
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ICAO Circular (1993). Investigation of human factors in accidents and incidents. 240-
AN/144. Montreal, Canada: International Civil Aviation Organization.
The ADREP database records results of aviation accident investigations conducted by ICAO
member states. The information is used to create aviation accident reduction programs. Each
aviation accident or incident is recorded as a series of events. Human factors topics are structured
into the SHEL model format which covers the individual, the human-environment interface, the
person-person aspect, and the person-software aspect. The SHEL model addresses the
importance of human interaction and the use of written information and symbology while
simultaneously allowing the Reason model on accident investigation to be applied.
Jensen, R. S. & Benel, R. A. (1977). Judgment evaluation and instruction in civil pilot
training (Final Report FAA-RD-78-24). Springfield, VA: National Technical Information
Service.
A taxonomy of pilot errors is developed. Three general behavioral categories are specified. The
first category is procedural activities. Flight activity examples included under this category are
setting switches, selecting frequencies, programming a computer and making communications.
These activities are characterized as discrete events that involve cognitive processes. The second
level is perceptual-motor activities. These types of activities involve continuous control
movements in response to what a pilot sees in the environment. The third level is decisional
activities. This involves cognitive activities and judgments and is the most difficult aspect to
handle in realistic flight environments. Using this taxonomy, total percentages for fatal and nonfatal
accidents from each category were calculated for a 4 year period. Procedural activities were
responsible for 4.6% of the fatal and 8.6% of the non-fatal accidents. Perceptual-motor activities
were responsible for 43.8% of the fatal and 56.3% of the non-fatal accidents. Decisional
activities were responsible for 51.6% of the fatal and 35.1% of the non-fatal accidents.
Johnson, W. B., & Rouse, W. B. (1982). Analysis and classification of human errors in
troubleshooting live aircraft power plants. IEEE Transactions on Systems, Man, and
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