human failure modes
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Human Failure Modes. Dr . Azad M. Madni Professor , Epstein Department of Industrial and Systems Engineering Director , SAE Program Co-Director, CSSE March 6, 2012. Outline. Human Failure Modes Demanding Systems Requirements Implications for Humans Evolving Human Roles - PowerPoint PPT PresentationTRANSCRIPT
Copyright © 2012 Azad Madni
Human Failure Modes
Dr. Azad M. MadniProfessor , Epstein Department of Industrial and Systems Engineering
Director, SAE ProgramCo-Director, CSSE
March 6, 2012
Copyright © 2012 Azad Madni
Outline
■ Human Failure Modes■ Demanding Systems Requirements■ Implications for Humans■ Evolving Human Roles■ Systems Engineering Mindset ■ The Remarkable Human Brain■ Human Error Sources■ Potential Remedies and Opportunities
Copyright © 2012 Azad Madni
Human Failure
■Comprises human errors, which are unintentional behaviors violations, which are willful disregard of rules and
regulations■Human errors fall into specific categories
slips, lapses of memorymistakes in following rules and proceduresmistakes in understanding
Copyright © 2012 Azad Madni
Demanding System Requirements
■ Adaptability■ Reconfigurability■ Composability■ Resilience
These requirements pose formidable challenges for humans that work with and within complex
systems
Copyright © 2012 Azad Madni
Implications for Humans
■System adaptability implies changing contexts and potential changes to human-system interactions
■System reconfigurability implies potential changes to human roles and human-system function allocation
■System resilience implies potential dynamic changes to human role and attendant changes to cognitive load
■System composability (as in SoSs) implies potential changes in collaborators (lack of shared conceptual model)These changes can increase likelihood of human
error.
Copyright © 2012 Azad Madni
Evolving Human Roles
■From that of operator outside system to that of agent within an adaptable system
decision maker supervisor monitor with override
authority re-assignable participant
(peer, assistant)These roles require new behaviors.
Copyright © 2012 Azad Madni
Systems Engineering Mindset
• Humans are suboptimal job performers that need to be shored up and compensated for during task performance
• This perception leads to systems that are inherently incompatible with human conceptualization of work
• The resulting mismatch inevitability creates human reliability issues that show up as human error
This mindset fails to capitalize on human ingenuity
Copyright © 2012 Azad Madni
The Remarkable Human Brain
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■ How ?
Source: LiveScience.com
Copyright © 2012 Azad Madni
Human Error Sources (Examples) ■ Erroneous/Incomplete Mental Model
often traceable to poor design- results in mistakes lack of complete info causes user to make
unwarranted assumptions about system state also results from misrecognition of cues/state info
■ Drop in Vigilance/Arousal during Monitoring occurs with infrequent stimulus leading to
missed cue detection ■ Loss of Focus during Task Performance
results in slips (execution errors) arising from inattention ■ Cognitive Overload
causes: multi-tasking, context switching, decision making under stress
can lead to suboptimal behaviors and human errors (mistakes and slips)
Copyright © 2012 Azad Madni
Key Findings
■ Humans change cognitive strategies under overload ■ Inverted-U relationship: performance & stress■ Humans unable to distribute attention under stress■ Adaptability of human-in-the-loop system is
upper-bounded by acceptable human error rate■ System inspectability facilitates human intervention
and avoids having to make erroneous assumptions■ For robust performance
need to minimize multitasking and context switching employ alerting/automation to monitor and flag rare events need to understand cognitive strategies under overload for effective aiding
Copyright © 2012 Azad Madni
Potential Remedies
■ Design human work to avoid multi-tasking and frequent context switching to the extent possible
■ Assign rare event monitoring to automation or alerting mechanisms
■ Provide decision aiding and performance support for decision making under stress
■ Design appropriate incentives to counter risk compensation tendency
■ Employ automation and dynamic function allocation to assure manageable cognitive loadMost complex problems will require a combination
of many of these remedies.
Copyright © 2012 Azad Madni
Potential Opportunities
■ Exploit human ingenuity and creativity in:adapting to shifting contextsgeneralizing from specificsrecognizing novelty and improvisingaggregating information in the absence of an algorithmdetecting and filling gaps (e.g., in narratives)
Most complex problems will require a combination of human creativity and ingenuity.
Copyright © 2012 Azad Madni
So,….Is Human Error a Cause or Consequence?
Thank You
Copyright © 2012 Azad Madni
My References
■ Madni, A.M. “Integrating Humans with Software and Systems: Technical Challenges and a Research Agenda,” Keynote Presentation, 22nd Annual Systems & Software Technology Council, Salt Lake City, Utah, April 26–29, 2010.
■ Madni, A.M. “Integrating Humans with Software and Systems: Technical Challenges and a Research Agenda,” INCOSE Journal of Systems Engineering and, Vol. 13, No. 3, 2010.
■ Madni, A.M. “Integrating Humans with Software and Systems: Technical Challenges and a Research Agenda,” Keynote Presentation, INCOSE 2010 LA Mini-Conference, Loyola Marymount University, October 16, 2010.
■ Madni, A.M. “Integrating Humans With and Within Software and Systems: Challenges and Opportunities,” (Invited Paper) CrossTalk, The Journal of Defense Software Engineering, May/June 2011, “People Solutions.”