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lead to unsafe acts (active failures). The final element is that defenses are safeguards against
foreseen hazards and can be inadequate (active and latent failures). Unsafe acts can be broken
down into different types. If actions are unintended, they can be slips or lapses. Slips are
attentional failures that can be caused by intrusions, omissions, reversals, misordering, or
mistiming. Lapses are memory failures that lead to omitting planned items, place-losing, and
forgetting. If actions are intended, they are classified as either mistakes or violations. Mistakes
are either rule-based where there is a misapplication of a good rule or and application of a bad
rule, or they can be knowledge-based. Violations are either routine, exceptional, or even acts of
sabotage. It is argued that accidents occur as a penetration of various levels of the framework
occurs. Latent errors combined with local triggering events lead to accidents and incidents.
40
Rockwell, T. H., & Giffin, W. C. (1987). General aviation pilot error modeling – Again?
Proceedings of the 4th International Symposium on Aviation Psychology (pp. 712-720).
Columbus, OH: The Ohio State University, The Aviation Psychology Laboratory.
Process models are created to initially explore three types of pilot error in general aviation. These
are visual flight rules (VFR) flight into instrumental meteorological conditions (IMC), pilot fuel
mismanagement, and pilot response to critical inflight events. The models are intended to explain
large percentages of accidents of a specific type, pin point specific research needs to understand
and to verify elements in the models, and to create implementable countermeasures to reduce the
probability of pilot error. The models depict decisional processes, list typical errors, contributing
factors and propose needed research.
Rouse, W. B. (1983). Models of human problem solving: Detection, diagnosis, and
compensation for system failures. Automatica (19), 613-625.
The paper looks at the role of the human operator as a problem solver in man-machine systems.
Various models of human problem solving are examined and a design for an overall model is
outlined. The overall model attempts to capture the whole of problem solving and be
operationalized within specific task domains. A basic mechanism for the proposed model
incorporates pattern recognition models. Problem solving occurs on three general levels. These
are recognition and classification, planning, and execution and monitory. The model can produce
the behavior of solving problems in a top-down and a bottom-up manner and almost
simultaneously on several levels.
41
Rouse, W. B., & Rouse, S. H. (1983). Analysis and classification of human error. IEEE
Transactions on Systems, Man, and Cybernetics, SMC-13(4), 539-549.
There are two major approaches to human error, probabilistic and causal. This paper deals with
the causal approach which focuses more on the why errors occur instead of just what occurs. It is
argued that classification schemes can generally be categorized in one of three ways. They can
be behavior-oriented, task-oriented, or system-oriented. Behavior-oriented schemes range from
those emphasizing basic human information processing to those that focus on types of behavior
occurring in particular task domains. Task-oriented schemes focus on information transfer
problems, distraction events, and discriminating among types of tasks. System-oriented schemes
apply categories of a relatively broad nature which cover a series of tasks within the domain of a
particular system. A methodology is developed and discussed with the goal of analyzing human
error in terms of causes as well as contributing factors and events. It borrows heavily from
several of the previously discussed classification schemes. There are four general classes of
contributing factors for human errors: Inherent human limitations, inherent system limitations,
contributing conditions, and contributing events. Inherent human limitations include the
knowledge and attitude of the operator. Inherent system limitations include the design of controls
and displays, design of dialogues and procedures, and level of simulator fidelity. Contributing
conditions include environmental factors such as noise, excessive workload, frustration, anger,
embarrassment, confusion and operating in degraded modes. Contributing events involve
distractions, lack of or misleading communication, sudden equipment failures, and events such
as tension release. The proposed methodology is used to reanalyze data reported by Rouse et al
having to do with the design and evaluation of computer-based methods for presenting
procedural information such as checklists for normal, abnormal, and emergency aircraft
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