Cog Exam

On average, how much do road deaths in New Zealand cost overall each year?

$4.8bn

Who created STAMP?

Leveson

Do STAMP and Accimap help predict accidents?

Can give us insight on hassle problems, which cause people minor problems during their daily work, but could become accidents under the right conditions.

When was the first recorded death from a "modern" vehicle?

1896

How many people died on the HOFE?

193, out of 500 on board

When did the HOFE incident occur?

1987

What do accidents in sociotechnical systems involve, according to Rasmussen's Risk Framework?

1: Multiple actors and levels 2: Multiple contributing factors 3: Vertical integration (lack of) 4: Feedback (lack of) 5: External pressure 6: Migration of work practices at multiple levels (happens over time, can lead to everyone being very lost as to what is going on in levels beyond their own) 7: Erosion of defences through migration of work practices (can lead to holes in the cheese).

What are the two approaches to improving safety?

1: Preventing accidents from happening (stopping people from doing things entirely) 2: Reduce negative consequences (make what people are doing safer, having a solid emergency response for when things do go wrong). In practise good to do a combination of both.

System approach to accident causes

Errors result from upstream system factors, e.g organisational processes.

When was the first recorded pedestrian death involving an automated vehicle?

2018

What is the definition of a near miss?

A serious error/incident/event that had the potential to cause harm but didn't due to conditions at the time.

What is an accident?

A short, sudden, and unexpected events that results in an unwanted or undesirable outcome. For cog, this directly or indirectly is the result of human activity.

What are some examples of Perceptual Errors in the field of aviation, following HFACS?

Errors which occur because the person's perception doesn't match reality. E.g visual illusion, spatial disorientation/vertigo, misjudged distance, altitude, airspeed, etc.

How many causes do maritime accidents have generally, according to a Dutch study?

7-58.

How often is human error implicated as fault in aviation accidents?

70-80%

How often is human error implicated as fault in marine casualties?

75-96%

How often is human error implicated as fault in road crashes?

90-95%,

What are some examples of Conditions of Operator precursors to unsafe acts, according to HFACS?

ADVERSE MENTAL STATE: Operator not mentally prepared. Can be temporary (stress, fatigue, distraction, etc), or persistent (personality traits, overconfidence, etc). ADVERSE PHYSIOLOGICAL STATES: Medical/physiological conditions. E.g fatigue, illness, drugs, motion sickness. PHYSICAL/MENTAL LIMITATIONS: Task requirements exceed the operator's capabilities. E.g visual processing, lack of sensory input, reaction time, information overload, inexperience, etc.

Person approach to accident causes

ALL HUMAN. Forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.

What are some examples of supervisory violations according to HFACS?

Authorised unqualified crew, failed to enforce rules and regulations, violated procedures, authorised unnecessary hazard etc.

Describe Reason's Swiss Cheese Model

Basically you have latent (organisational) failures, which when combined with the right intervening factors (task/environmental conditions), and active failures (unsafe acts), you get an accident.

What influence did WW2 have on the field of human factors?

Before the war, people focused on matching individuals to jobs. During the war, people struggled with the physical and cognitive demands of complex devices and systems. Post-war, the emphasis shifted to system design and complex task performance.

What are examples of inadequate execution of control action Control Failures, according to STAMP?

Communication flaws, inadequate actuator operation, time lag.

What are characteristics of cognitive engineering?

Complex world, system oriented, multiple cognitive agents engaged at once. Ecological, practical (goal is improved performance), and problem driven.

According to STAMP, what do accidents result form?

Control failures at all system levels.

What are the two components of conducting a STAMP analysis?

Control structure, and identify failures at each control structure.

How can we achieve the goals of cognitive engineering?

DESIGN: think about peoples capacities and limitations SELECTION + TRAINING: Identify individual differences, and prepare people for their tasks. COMPLEMENTARY

Describe the STAMP control structure

DRAW

What are some examples of technological environment factors that can be a precursor for unsafe acts, according to HFACS?

Design of equipment and controls, checklist layout, display/interface characteristics, automation.

What are the subcategories for preconditions to unsafe acts according to HFACS?

ENVIRONMENTAL: Physical + technological environment. CONDITION OF OPERATORS: Mental + physical limitations, adverse physiological states, adverse mental states. PERSONNEL FACTORS: Crew resource management, personnel readiness.

What are the subcategories for unsafe acts according to HFACS?

ERRORS: Skill-based, decision, perceptual. VIOLATIONS: Routine, exceptional.

What are some examples of Failing to Correct a Known Problem, as a subcategory of unsafe supervision, according to HFACS?

Failed to identify or correct inappropriate behaviour/a safety hazard. Failed to initiate corrective action. Failed to report unsafe tendencies. SUPERVISOR AWARE OF A PROBLEM BUT NOT DOING ANYTHING ABOUT IT.

What are some Personal Readiness factors which can be a precursor to unsafe acts, according to HFACS?

Failing to adhere to rest requirements, inadequate training, bad off-duty behaviour e.g drugs etc, poor risk judgement.

Persons approach to countermeasures to avoid accidents

Fear campaigns, policies and procedures, disciplinary action, litigation, retraining, name, blame, and shame.

What does a risk triangle consist of?

For each fatal accident there were ... serious incidents and ... occurrences (or near misses). Proportions vary over time.

What are the levels of Rasmussen's Accimap?

Govt <-> regulators, associations <-> company <-> management <-> staff <-> work (where the hazards are). Feedback and interactions between any and all levels, in BOTH DIRECTIONS.

What are some examples of ROUTINE violations in the field of aviation, following HFACS?

HABITUAL, TOLERATED BY AUTHORITY. Inadequate briefing, unauthorised approach, violated training rules, etc. WORK AS DONE VS WORK AS IMAGINED.

Differences between HFACS and Accimap

HFACS linear, all within company. Accimap recognises that safety impacts by every person within a system, and accidents usually are caused by a lack of vertical integration across levels of a system (e.g lack of communication between the CEOs and the workers). Big difference is Accimap looks beyond the company level.

What are some Resource Management problems within an organisation which could lead to an accident, according to HFACS?

HUMAN RESOURCES: Staffing, selection. background checks, training BUDGET: Excessive cost cutting, lack of funding EQUIPMENT/FACILITIES: Poor design, unsuitable equipment, failure to correct design flaws.

Does HFACS help us predict accidents?

Kind of, focuses on what went wrong in accidents, but doesn't help us learn from near misses.

What is relative risk in terms of behaviour and accidents?

How common are particular behaviours in accidents, relative to how frequently those behaviours occur in general? E.g some behaviours are common in accidents just bc they're common generally, like a driver talking to their passenger. Others are common bc they increase the risk of incidents/adverse outcomes e.g not wearing a seatbelt.

What does HFACS stand for?

Human Factors Analysis and Classification System

Outline Shorrock's "The human factor".

Human element of human-technology interactions. Humans hold balme when stuff goes wrong. Used by people interested in PERFORMANCE. Usually in the context of UNWANTED performance e.g crashes etc. Can be quite negative.

What are the main characteristics of the NEW approach to human error?

Human error is a symptom of problems across the system. It is a CONSEQUENCE of failure, NOT A CAUSE of it. Incidents are caused by multiple interacting factors. In order to understand failure we should look at why peoples actions made sense at the time. SYSTEMS ARE UNSAFE, HUMANS CREATE SAFETY THROUGH PRACTISES AT ALL LEVELS OF THE SYSTEM.

What are the main characteristics of the OLD approach to human error?

Human error is the cause of accidents. In order to understand failure, you should only examine failures. SYSTEMS ARE SAFE, UNRELIABLE HUMANS MAKE THEM UNSAFE. Systems can be made safer by restricting humans through automation etc.

Outline Shorrock's "Sociotechnical system interaction"

Human factors aims to understand how humans interact with technology and other aspects of socio-technical systems. HUMAND AND NON-HUMAN AGENTS. CONSIDERS CONTEXT WHICH THE OTHERS DON'T DO - why are people acting and interacting in this way? Takes responsibility away which can be seen as bad, people don't know who to blame.

Outline Shorrock's "Factors OF humans"

Humans have innate capabilities and limitations. Need to understand these in order to create usable systems. Helps us understand WHY people make mistakes. Important to understand, but limited in some aspects: REDUCTIONIST: reduces people to their cognitive abilities, PIECEMEAL SOLUTIONS: Might only look at one aspect of peoples cognition at once, which could lead to other cognition problems. Sometimes tricky to make sure lab research is applicable to the real world.

What is a lagging indicator?

Identified after an incident occurs. E.g only find out what caused the accident after it happened. Reactive to loss, death.

What role does confirmation bias play in safety research?

If you think speed is the cause of the crash, you might not look for other factors that may have caused the crash. So for example someone might have been speeding, but because their brakes weren't working they crashed. Whilst speed played a role, the main cause would have been the brake problem.

What are the goals of cognitive engineering?

Improving safety, enhancing usability, and improving efficiency and productivity.

What are some Crew Resource Management factors which can be a precursor for unsafe acts, according to HFACS?

Inadequate briefing, lack of teamwork, poor communication, etc.

What are the subcategories of unsafe supervision in HFACS?

Inadequate supervision, planned inappropriate operations, failing to correct a problem, supervisory violations.

In healthcare, what are adverse events? Give some examples.

Injuries arising FROM medical care. E.g drug treatment errors, errors in use of medical devices, surgical and anaesthesia errors, infections acquired IN hospital, etc.

What is good about Sweden's Vision Zero programme?

It takes a systems approach. Humans make mistakes, so our road system should be designed to protect us.

Who coined the term "ergonomics" and when?

KF Hywel Murrell, in the 1940s, to describe his military research he conducted in WW2.

Why did Leveson propose the STAMP model of accident analysis, when both HFACS and Accimap already existed?

Leveson argued new accident models were needed due to the fast pace of technological change, changing nature of accidents, new types of hazards, increasing complexity and coupling, more complex relationships between humans and automation, decreasing tolerance for single BIG accidents, and changing regulatory and public views of safety.

What were other factors (not immediate) that contributed to the Mangatepopo Gorge incident?

Limited instructor experience in the gorge, hadn't been to all the trainings - flawed evacuation plan. Poor communication of plan within system. No radio comms bc they weren't waterproof. Varying levels of swimming experience. Trainings were inadequate, risk assessments were inadequate, financial and production pressures on OPC for them to operate regardless of weather, no regulatory body, crappy auditing process - process also distracted ppl which contributed to disaster, issues with weather reports, miscommunication about the days activities.

What are some critiques of Reason's Swiss Cheese Model?

Limited practical application, implies a linear approach which is not always the case.

Why were no individuals prosecuted in the Mangatepopo Gorge incident?

Many systemic problems were at play.

What is a leading indicator?

Measurable precursors to incidents. Proactive prevention of incidents through management. As systems become safer it is harder to learn from your mistakes because there are less mistakes to learn from.

What is the definition of cognitive ergonomics?

Mental work done in the context of machines.

What is the Hawthorne (observer) effect?

Motivation and external factors can influence performance. E.g the mere presence of someone watching a worker can influence their behaviour.

Outline Rasmussen's Risk Framework

NEED TO DRAW. Basically have a gradient toward Least Effort, which pushes you towards the boundary of acceptable performance. Management pressure toward efficiency does the same. Counter gradient from campaigns for safety culture pushes you towards economic failure and unacceptable workload.

What are examples of inadequate or missing feedback Control Failures, according to STAMP?

Not provided in system design, communication flaw, time lag, inadequate sensor operation (incorrect or no information provided).

What are some examples of EXCEPTIONAL violations in the field of aviation, following HFACS?

ONE-OFF deviations from rules or procedures. E.g unauthorised aerobatic manoeuvre, improper takeover technique, failed to obtain valid weather brief, not qualified, etc.

What are some examples of physical environment factors that can be a precursor for unsafe acts, according to HFACS?

OPERATIONAL EQUIPMENT: Weather, altitude, terrain AMBIENT ENVIRONMENT: Heat, lighting, vibration, toxins.

What are some Organisational Process problems within an organisation which could lead to an accident, according to HFACS?

OPERATIONS: Incentives, time pressure, quotas, schedules. PROCEDURES: Standards, objectives, procedures and instructions. OVERSIGHT: Safety/risk management, monitoring and checking by management.

Briefly describe the Piper Alpha incident, including what happened, and what systemic problems were in place which led to its occurrence.

Oil platform on the North Sea. Exploded in 1988, killing 167. Loss of around 1.7 billion pounds. PROBLEMS: Platform continued to operate even though it was getting upgraded, redundant pumps were inoperative, were only fixing stuff that was clearly broken - not checking everything for minor damage, NO CONTINGENCY PLAN for when the control office was destroyed by the explosion, hard to evacuate. INSUFFICIENT REDUNDANCIES AND CONTINGENCY PLANS

Outline HFACS

Organisational influences - unsafe supervision - preconditions for unsafe acts - unsafe acts - ACCIDENT

What are latent failures according to Reason's Swiss Cheese Model?

Organisational processes. Such as poor design, operation, maintenance, communication, etc.

What are the pros and cons of STAMP?

PROS: Additional data compared to HFACS and Accimap. As/more comprehensive than Accimap, depending on data available. Includes generic error taxonomy. CONS: Confusing for someone without an engineering background, terminology not the easiest to understand. Only puts things into three categories. Misses out some info, like people on the same level can influence each other.

Pros and Cons of Rasmussen's Accimap

PROS: Can tailor it to your specific incident, e.g aggregate accimaps (across multiple incidents), and time-linked accimaps (different stages leading up to an accident). Actions and failures are explicitly linked. Considers more levels of a system than HFACS. CONS: Doesn't provide a taxonomy of error/actions. No consistency bc you can tailor it so much, so low inter-rater reliability. Lacks some details because it focuses on actions and decisions, but not WHY those actions and decisions were made.

Pros and Cons of HFACS

PROS: Provides a structured taxonomy, which improves inter-rater reliability. Useful for collating data from multiple incidents. CONS: Needs to be adapted to other contexts, not just aviation, the taxonomy might not always fit every situation. Misses out on everything that happens above the company level, e.g influences of an auditing company, or company sponsors etc.

Systems approach to countermeasures to avoid accidents

People are human and WILL make mistakes; systems should contain appropriate defences and redundancies to try and minimise these mistakes and their impacts.

What are some examples of Planned Inappropriate Operations according to HFACS?

Poor crew pairing, failing to provide adequate time for supervision and briefing, risks outweighing benefits, failing to provide adequate rest opportunities, excessive tasking/workload.

Who was Accimap created by?

Rasmussen

What is HFACS based on?

Reason's Swiss Cheese model

What are the subcategories of organisational influences in HFACS?

Resource management, organisational climate, organisational process.

What were the immediate causes of the Mangatepopo Gorge incident?

Rising water and the instructor's decision to leave their ledge and enter the water.

What are the implications of Rasmussen's Risk Framework?

Risk management is a dynamic process, with changes constantly happening and coming from all directions. Risk management is a control function, need to think about who implements the controls, and at what levels they are implemented, and whether they can be improved. We can control behaviour by making boundaries explicit, and helping people develop "coping skills", which increase the margins at boundaries - give us a bigger safety buffer.

What was the design of the ship, the HOFE?

Roll-on roll-of

What were some precursors to the study of cognitive engineering in the late 19th/early 20th centuries?

SCIENTIFIC MANAGEMENT: Pioneered by Winslow Taylor, focused on maximising output. TIME AND MOTION STUDIES: Pioneered by the Gilbreths, looked at how people do tasks.

What are some Organisational Climate problems within an organisation which could lead to an accident, according to HFACS?

STRUCTURE: Chain of command, communication, delegation, accountability. POLICIES: HR, drugs and alcohol, accident investigation. CULTURE: Norms and rules, customs, beliefs, values, attitudes.

What is the definition of human factors?

Scientific discipline concerned with understanding of INTERACTIONS among HUMANS and other elements of a SYSTEM, and the profession associated which applies methods to DESIGN in order to OPTIMISE HUMAN WELLBEING and overall SYSTEM PERFORMANCE.

What are some examples of inadequate supervision according to HFACS?

Supervisor failed to provide proper training, professional guidance and oversight, and adequate rest period, track qualifications and performance. A lack of accountability, perceived lack of authority, an inadequately trained/overworked supervisor, or loss of supervisory situation awareness (e.g work-as-done vs. work-as-imagined).

What are the differences between Reason's Swiss Cheese Model and HFACS?

Swiss Cheese Model has a theoretical basis, Weigmann and Shappell (2003) adapted it to real aviation situations. Defined the "holes in the cheese", made it practical and easy to understand.

What does STAMP stand for?

Systems Theoretic Accident Model and Processes

What are the fundamental characteristics of human factors and ergonomics?

Systems approach, design driven, and focuses on performance AND well-being.

What are intervening factors according to Reason's Swiss Cheese Model?

Task and environmental conditions. Bad ones can trigger an accident.

What is the definition of Cognitive Engineering?

The study of factors that affect decision making and cognition in naturalistic task settings.

What were Shorrock's 4 types of human factors?

The human factor. Factors OF humans. Factors AFFECTING humans. Sociotechnical system interaction.

What is the definition of ergonomics?

The scientific study of work

Outline Shorrock's "Factors AFFECTING humans"

There are external and internal factors that affect performance. E.g organisational issues, environment, work design, and factors OF humans. Acknowledges external factors can influence performance. Emphasises DESIGN, TRAINING, SUPERVISION. Error focus

What are the differences between Rasmussen's Accimap hierarchy, and Leveson's STAMP hierarchy?

They're fairly similar. Leveson thought Accimap focused too much on the lower levels of the system, thought it should be more about design, and what was wrong with the way the system was planned in the first place.

What are examples of Inadequate enforcement on constraints Control Failures, according to STAMP?

Unidentified hazards. Inappropriate, ineffective, or missing control actions for identified hazards (design doesn't enforce constraints; process models inconsistent, incomplete, or incorrect; inadequate coordination among controllers and decision makers).

What are active failures according to Reason's Swiss Cheese Model?

Unsafe acts - PEOPLE'S DIRECT ACTIONS. E.g errors and violations.

What are some examples of Skills-Based Errors in the field of aviation, following HFACS?

When something is so routine you become more likely to mess up. Distraction, task overload, misprioritised attention, over-reliance on automation, etc.

What are some examples of Decision Errors in the field of aviation, following HFACS?

When things are going to plan, but the plan is wrong. HONEST MISTAKES - plan isn't good enough. Inappropriate manoeuvre or procedure, inadequate knowledge of systems or procedures, exceeded ability, wrong response to emergency.

Does HFACS help us prevent accidents?

Yes, because it can help eliminate what went wrong to cause prior accidents.

Can STAMP help prevent accidents?

Yes, by enforcing controls and constraints and helping encourage communication across levels in a hierarchy.