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described and defined by key steps in the process that are linked to decision making states.
Awareness of the situation as a result of monitoring is the first step. From here, risk of current
and alternative courses of action is assessed. This leads to time assessment which is a critical
factor in decision making for dynamic environments. Finally, further options are generated.
O’Hare, D. (in press). The “wheel of misfortune”: A taxonomic approach to human factors
in accident investigation and analysis in aviation and other complex systems. Ergonomics.
The Reason model of human error has been very influential in accident investigation because of
its complexity and breadth. However, a major criticism for using this model as an accident
causation model is its linear sequence of levels instead of considering intersecting influences
from various points. A revised theoretical model and associated classification framework is
proposed to help guide the accident investigation process. It is named the Wheel of Misfortune.
There are three concentric spheres in this model. The innermost circle represents the actions of
the front line personnel. The middle circle represents local precipitating conditions. The
outermost circle represents the global conditions generated by organizations. Actions of the
individual operator are described in terms of an internal function taxonomy. This taxonomy
includes the Skill-Rule-Knowledge framework that Rasmussen developed. The local conditions
circle includes factors that may be critical in the breakdown of human performance in complex
systems. These include weather and internal states of the flightcrew among other factors. The
global conditions circle considers the context within which the task activity takes place. This
includes organizational processes. This model has three potentially valuable functions. The
concentric spheres within spheres are better than the linear sequence of factors in representing
accident causation. This provides an alternative to Reason’s Swiss Cheese model. In the wheel of
misfortune, the strength of a system is determined by the outer shell of the model. The model is
also good for directing the attention of the investigator to specific questions within the layers of
concern such as local actions, immediate realities of the operational environment, and influences
of organizational functioning. A final benefit is that the model is expressed in terms of general
processes which are independent of functioning within any specific domain. This allows
information from other models to be used in this framework. The model is similar to the
“Taxonomy of Unsafe Operations” model of Shappell and Wiegmann, but uses a representation
at a higher level of abstraction that gives greater comprehensiveness and parsimony.
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O’Hare, D., Wiggins, M., Batt, R., & Morrison, D. (1994). Cognitive failure analysis for
aircraft accident investigation. Ergonomics, 37(11), 1855-1869.
Two studies were conducted to investigate the applicability of an information processing
approach to human failure in the aircraft cockpit. In the first study, the authors attempt to
validate Nagel’s three stage information processing model of human performance. The model
confirmed that decisional factors are extremely important in fatal accidents. It is determined that
Nagel’s model is and oversimplification. There are at least five, not three, distinct categories of
errors that can occur in the cockpit. These are perceptual, decisional, procedural, monitoring, and
handling errors. In the second study, the authors develop a more detailed analysis of cognitive
errors based on a theoretical model proposed by Rasmussen and further developed by Rouse and
Rouse. A taxonomic algorithm that was derived from Rasmussen’s work was used to classify
information processing failures. The algorithm focused on structural and mechanical errors,
information errors, diagnostic errors, goal errors, strategy errors, procedure errors, and action
errors.
Paradies, M. (1991). Root cause analysis and human factors. Human Factors Society
Bulletin, 34(8), 1-6.
Root cause analysis attempts to achieve operator excellence by establishing an aggressive
program to review the accidents, determine their root causes, and take prompt corrective action.
Event investigation systems seem to be successful when they contain certain basic
characteristics. They need to identify the event’s sequence, set a goal to find a fixable root cause,
avoid placing blame, be easy for investigators to learn and use, and be easy for managers to
understand and provide an easily understood graphic display of the event for management
review.
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