Research article

Journal of Cognitive Engineering

and Decision Making
Understanding Automation Failure 2023, Vol. 0(0) 1–8
© 2023, Human Factors
and Ergonomics Society
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/15553434231222059
Mica R. Endsley  journals.sagepub.com/home/edm

Abstract
The implementation of automation in many domains has led to well-documented accidents and incidents,
resulting from reduced situation awareness that occurs when operators are out-of-loop (OOTL), au-
tomation confusion, and automation interaction difficulties. Wickens coined the term lumberjack effect to
summarize the finding that while automation works well most of the time in typical or normal situations,
the performance problems that occur in novel or unexpected situations also increase the likelihood of
catastrophic errors. Skraaning and Jamieson have criticized the lumberjack effect due to a study in which
they failed to find it. I show that this claim is unsupported due to a number of methodological limitations in
their study and conceptual errors. They also provide a model of automation failure that fails to clearly
delineate the many barriers to accidents that are available, instead emphasizing the ways in which au-
tomation can fail technically and different types of human error. An alternate automation failure model is
presented that provides a broader socio-technical perspective emphasizing the design features, processes,
capabilities, organizational policies, and training that support people in improving system safety when
automation fails.

Keywords
errors, topics, automation, topics, human-automation interaction, topics, level of automation, topics,
situation awareness, topics

Automation-Induced Failures Gawron (2019) documents 26 automation-

Severe accidents and safety compromising inci-
dents are a well-known side effect of automation
(Wiener, 1988). These accidents arise from a
number of automation problems, largely induced
by the design of these systems, that affect people’s
ability to oversee and interact with it in order to
maintain operational safety. This includes (a) au-
tomation confusion where operators have trouble
in understanding what the automation is doing, (b)
reduced situation awareness (SA) that results from
being out-of-the-loop (OOTL) leading to slow
detection and response to events that the auto-
mation cannot handle, and (c) automation inter-
action difficulties where people have problems
directing the automation, particularly in time-
critical situations.
related aircraft accidents and incidents. In re-
viewing this list, 27% can be categorized as in-
volving automation confusion, 58% as OOTL/SA
problems, and 36% involved automation interac-
tion problems (with some accidents having mul-
tiple problems). Contributing to these challenges
were problems with (a) 61% of cases having highly
complex automation logic not performing as ex-
pected or as appropriate for the situation, (b) 38%
of cases having mode errors in which the wrong
SA Technologies, Gold Canyon, AZ, USA
Corresponding Author:
Mica R. Endsley, SA Technologies, 5301 S. Superstition
Mountain Drive, #104377, Gold Canyon, AZ 85118, USA.
Email: mica@satechnologies.com
2 Journal of Cognitive Engineering and Decision Making 0(0)
mode was accidentally selected or the system was
accidentally disengaged, and (c) 8% of cases in-
volving erroneous inputs causing the automation
to perform incorrectly for the situation.
Based on this history, Wickens (Onnasch et al.,
2014; Sebok & Wickens, 2017) coined the term
“lumberjack effect” to refer to the general finding that
while automation may work well most of the time in
typical or normal situations, the performance prob-
lems that occur in novel or unexpected situations also
increase the likelihood of catastrophic errors. This
generalization of the problem summarizes these real-
world findings in which automation-related accidents
arise in edge case situations that the automation may
not be designed to handle, where it acts inappropri-
ately due to inaccurate inputs, and where it adds extra
complexity to the operators’ job. The challenge lies
not just in the robustness and appropriateness of the
systems’ programming, but also in many deficiencies
in the design of the human-automation interaction and
resultant deficiencies in SA. While not specific to just
the OOTL problem, the lumberjack effect includes
OOTL SA deficits within its purview.
Automation Failures
Skraaning and Jamieson (2023) believe that there
is a need to better define the concept of automation
failure in order to ensure that researchers more
clearly understand the nature of the event, par-
ticularly in the context of automation-related hu-
man performance challenges. I agree with them
that it is worthwhile to fully define what is meant
by automation failure; however, their proposed
taxonomy has several drawbacks.
(1) It fails to distinguish causes from effects, falling
short of providing either a taxonomy or a model
of automation failure. It includes elements and
systemic causes of automation failure charac-
terizing a number of difficult types of short-
comings that can occur within the automation
(e.g., logic deficiencies, programming errors,
and malfunctioning hardware) as well as inputs
to the automation (such as sensor failures) and
combinatorial effects from interactions between
automated systems. It also includes a partial list
of human-automation interaction problems, and
a partial list of human/organizational slips or
misconceptions. These categories are
somewhat overlapping however. For example,
inadvertent activation/deactivation of automa-
tion is listed as a human/organizational slip
(which may be a precipitating input to an ac-
cident), but it is also the outcome of poor
human-automation interface design. An oper-
ator’s incorrect mental model may be due to
inadequate training (listed as human/
organizational slips) or due to overly com-
plex and hidden automation (listed as a human-
automation interaction breakdowns). Yet the
fact that the automation logic is highly complex
in the first place does not seem to be listed as a
failure of the automation design itself.
(2) If fails to provide a socio-technical view of error
that can assist automation developers in
avoiding negative outcomes, instead blaming
the operator at the pointy end of the stick for
errors (Woods et al., 2017). For example, the
human and organizational slips/misconceptions
all cite the operator as performing improperly in
some way without identifying these issues as a
consequence of automation design features or
organizational actions.
(3) No evidence is provided that many of the factors
in the taxonomy (i.e., different etiologies for
automation failure) matter in terms of differ-
ential effects on human performance with au-
tomation. That is, while I agree that the list of
potential automation problems may be a good
one, and any or all of them may be at fault in a
given accident, there is no evidence at present
that the nature of human response to the auto-
mation fault will be different based on the
13 categories of failure listed. In the review of
automation accidents in the aviation field pro-
vided by Gawron (2019), for example, only a
subset of these automation problems is ob-
served, and there is no clear difference in the
subsequent outcomes.
Prevention of Automation-Induced
Performance Failures
As a remedy to these shortcomings, Figure 1
shows an alternate depiction of automation fail-
ure, clearly distinguishing inputs from outputs as
well as relevant intervention factors. The model
depicts a number of factors that mediate between
Endsley
particular automation-related events and negative
outcomes of concern. This approach more clearly
illustrates that accidents are not a direct result of
just an automation failure, but that a series of
barriers to error are available (Reason, 2000). In
this light, automation accidents are not the sole
result of operator error, but rather induced by a
series of predicating events and automation fea-
tures as well as failures to provide tools, capa-
bilities, policies, and training that support people
in improving system safety under these condi-
tions. This depiction more clearly emphasizes the
specific actions that system developers and or-
ganizations can take to maintain operational
safety by reducing the occurrence of human
performance problems in the face of failure
events.
OOTL, SA, and Level of
Automation—Tempests in Teapots
Skraaning and Jamieson (Jamieson & Skraaning,
2020a, 2020b; Skraaning & Jamieson, 2023)
criticize the lumberjack effect on the basis of their
inability to find it in a study they conducted in a
nuclear power simulation with an automated aid
for performing a checklist. They believe the reason
for this is that their study was conducted in a high-
Figure 1. Anatomy of automation failure: Barriers for the prevention of human performance degradation.
3
fidelity simulator with experienced power plant
operators (Jamieson & Skraaning, 2018).
Wickens et al. (2020) disputed their criticism of
the lumberjack effect on the basis that their find-
ings were limited due to:
(1) The automation failure involved a malfunc-
tion in an underlying relief valve, not the
automation itself,
(2) Reliance on an unvalidated measure of SA
called the Important Parameter Assessment
Questionnaire (IPAQ),
(3) Discounting participants’ negative ratings of
the high level of automation (LOA) condi-
tions that were consistent with lumberjack
predictions and highly significant,
(4) Lack of statistical power associated with a
small sample size, and
(5) Lack of comparison between routine and
abnormal conditions.
While I agree with Skraaning and Jamieson (2023)
that the automation failure condition in their study
was relevant in terms of being representative of many
automation failures, disputing point 1, I largely agree
with Wickens et al.’s (2020) other four points. There
are a number of issues, both methodological and
conceptual, that significantly limit the generalizability
of the Jamieson and Skraaning (2020a) study.
4 Journal of Cognitive Engineering and Decision Making 0(0)
Methodological Limitations
Small Sample Size. The study involved only eight
teams of operators each performing in four auto-
mation conditions, providing only eight measures of
performance per condition. This is an extremely small
number to detect differences between conditions.
While Skraaning and Jamieson argue that somehow
the power of the test is not important, this fails to
address a key limitation of their study: perhaps eight
measures of an event in each condition is simply
insufficient for showing statistical significance be-
tween conditions? Another study cited by Skraaning
and Jamieson as contradicting the lumberjack effect is
Calhoun et al. (2009). Yet that study only had six
participants, an issue that its authors credited for the
performance measure failing to reach statistical sig-
nificance even though the trends followed the ex-
pected direction of higher LOA yielding slower
performance when the automation is unreliable (p =
.16). Similarly, Cummings and Mitchell (2007) had
only three participants in each LOA condition, yet
still found that high automation (management by
exception) was worse for performance (p = .07),
particularly when there were a high number of re-
planning events. Skraaning and Jamison do not
provide any trend data.
Limits of Testing. The Jamieson and Skraaning
study involved eight teams (of three people each)
performing in four scenarios. All scenarios in-
volved a fault in which one valve remained open,
varying only in terms of which valve and why it
failed to open. After the first fault, it is highly
unlikely the operators were surprised or not ex-
pecting a fault in the remaining scenarios. The
authors do not report on any testing of order effects
which could easily have contributed to the lack of
statistically significant difference between condi-
tions. With four LOA conditions and only eight
teams, attempts at counter-balancing for order
effects will have been only partial at best.
Poor SA Measure. Skraaning and Jamieson relied
on IPAQ as a measure of SA. Yet this is an un-
validated measure that has not been used in any
published literature. Their only citations for it are
two unpublished internal documents from an or-
ganization that no longer exists and are not pub-
licly available. This measure, administered at the
end of the scenario, asked for operators to rate the
importance of eight process parameters. As a key
limitation, by assessing this information only at the
end of the scenario, it is likely to only capture
operators’ understanding at that point, well after
participants may have figured out what was going
on in the scenario (Endsley, 2021). Thus, it does
not necessarily capture people’s SA at the time of
the anomalous event or any delays in ascertaining
what was really happening that could lead to
negative outcomes in many domains. The measure
therefore may suffer from significant hindsight
bias. Further, a high degree of overlap is shown in
the 95% confidence intervals on this measure
between the four LOA conditions casting some
doubt on the strength of their findings of SA
differences between conditions.
Other Relevant Factors. There are several other
factors that also could have contributed the lack of
an LOA performance effect in the Jamieson and
Skraaning study. The negative effects of high
LOAs have been shown to be worse for continuous
control tasks and those involving advanced
queueing of tasks (Endsley & Kaber, 1999; Kaber
et al., 2000), and when other tasks are present that
compete for people’s attention (Kaber & Endsley,
2004). The Jamieson and Skraaning study, how-
ever, involved a checklist that operators were
working through with different levels of automa-
tion. This type of task, particularly with no
competing tasks, is less likely to fall prey to OOTL
problems.
Secondly, it has been shown that display
transparency can reduce or eliminate OOTL per-
formance decrements (Bagheri & Jamieson, 2004;
Bass et al., 2013; Bean et al., 2011; Dzindolet
et al., 2002; Mercado et al., 2016; Selkowitz et al.,
2017; Seppelt & Lee, 2007; Stowers et al., 2017) as
well as SA problems (Boyce et al., 2015; Chen
et al., 2014; Schmitt et al., 2018; Selkowitz, et al.,
2017). It is entirely possible that Jamieson and
Skraaning did a good job in providing automation
transparency with their automated checklist dis-
play design. While it cannot be stated categorically
that either of these factors contributed to the lack of
significant differences in failure detection perfor-
mance between LOAs in their study, neither can
they be ruled out with enough certainty to call the
lumberjack effect into question.
Endsley
Conceptual Errors
More than OOTL. Much discussion about the
lumberjack effect is built around studies of OOTL.
However, it is worth pointing out that automation-
related performance problems result from not just
OOTL, but also automation confusion and auto-
mation interaction errors. Wicken’s description of
the lumberjack effect is not limited to OOTL;
rather, catastrophic events can happen due to au-
tomation problems of varying kinds.
Probabilistic versus Deterministic Models. Much of
Skraaning and Jamieson’s argument lies in the
presumption that the “burden of proof for a pre-
diction of human performance effects rests on
those making the prediction,” and that even a few
studies that have findings that contradict that
model are enough to cast doubt on it. This
viewpoint would only hold true if the lumberjack
effect were deterministic rather than probabilistic.
In fact, it is plainly obvious that automation in
many cases works well much of the time and that
people are often able to detect and correct for its
shortcomings, or it would never be implemented at
all. Rather, the lumberjack effect merely states that
the probability of these OOTL events increases
with automation. The more detailed research lit-
erature provides information on the many factors
that affect that probability (e.g., LOA, competing
tasks, time on task, task implementation, display
transparency, and training) (Endsley, 2017b).
As for the burden of proof, not only does the
wide body of research literature on this matter
show a preponderance of evidence for the effect of
LOA on OOTL from laboratory studies (Onnasch,
et al., 2014) but also a large body of real-world
examples (e.g. Gawron, 2019) shows that these
problems are not just the result of the artificialities
of the laboratory, but are a significant problem in
complex settings with experienced operators.
SA and LOA. Some confusion seems to exist on the
effects of higher LOAs on SA. The research base
includes studies that show increases in SA at
higher LOAs (Endsley & Kaber, 1999; Ma &
Kaber, 2005); however, most studies show de-
creases in SA at higher LOAs (Endsley & Kiris,
1995; Franz et al., 2015; Jipp & Ackerman, 2016;
Kaber, et al., 2000; Manzey et al., 2012;
5
Sethumadhavan, 2009). Understanding this ap-
parent discrepancy relies on looking more closely
at the data.
High LOAs can have the advantage of freeing
up cognitive resources so that people have more
time to take-in information, at least initially. But
when secondary tasks are introduced, this potential
benefit disappears (Kaber & Endsley, 2004; Ma &
Kaber, 2005; Weaver & DeLucia, 2022). En-
gagement decreases and attention to other tasks
increases over time, lowering SA on automation-
related information (Carsten et al., 2012) and in-
creasing complacency (Wickens et al., 2015). This
is more likely with automation that is more reliable
which acts to increase trust (Wickens & Dixon,
2007). SA essentially can become more variable
under increased automation, increasing with effort,
but decreasing during periods of distraction and
higher workload (Endsley, 2017a). Importantly,
studies have shown a significant correlation be-
tween SA and manual take-over time following an
automation problem (Clark et al., 2017;
Sethumadhavan, 2009), demonstrating the im-
portance of SA at the time that an event occurs for
people’s ability to recover from the automation
failure.
Thus, if SA actually did increase in the higher
LOA conditions in Skraaning and Jamieson’s
studies (which is questionable given their measure
of SA), it would not be particularly damning with
respect to the lumberjack effect. Rather it is
somewhat consistent for a study in which partic-
ipants were not subject to dual tasking.
Task Complexity. Jamieson and Skraaning’s central
rationale for not finding an OOTL effect centers on
the fact that their study employed experienced
operators in a high-fidelity simulation environ-
ment, claiming the lumberjack effect does not
extend to complex environments. However, there
is not much evidence to back up this claim. Two of
the other studies cited as additional evidence by
Jamieson and Skraaning also had a very small
number of inexperienced participants, with their
trends generally supporting the lumberjack effect
(Calhoun, et al., 2009; Cummings & Mitchell,
2007). The third study employed 20 experienced
air traffic controllers using a conflict detection aid
(Metzger & Parasuraman, 2005). It also supports
the lumberjack effect showing improved
6 Journal of Cognitive Engineering and Decision Making 0(0)
performance with the aid in normal situations (p =
.01) and a trend toward better manual performance
compared to with the automated aid when it was
unreliable (p = .14). The authors felt this finding
had practical significance in safety critical envi-
ronments, particularly since order effects were
present and the less reliable condition was always
presented last. SA was not measured in that study.
While many experimental research studies that
have been done in this area employed either low-
or medium-fidelity simulations, the large number
of accidents and incidents from highly complex
settings in the real world with experienced oper-
ators discussed at the beginning of this paper
shows that the OOTL event occurs outside of
laboratory settings as well.
Conclusions
Skraaning and Jamieson’s “failure to find auto-
mation failure” is far more the result of significant
methodological issues, conceptual errors, and
logical flaws than it is of any shortcomings in the
well-documented OOTL phenomenon. There is
little reason (in their words) to “throw the baby out
with the bath water.” Endsley (2017b) and
Onnasch et al. (2014) reviews of experimental
research on this concept over the past 40 years add
significant depth to our understanding of the
OOTL phenomenon that has been repeatedly
demonstrated in complex, real-world settings, with
sometimes catastrophic effects. Importantly, the
lumberjack effect and the human-autonomy sys-
tem oversight (HASO) model (Endsley, 2017b)
demonstrate predictive validity, with a new crop of
accidents being found for automobile automation
of continuous control functions (Siddiqui &
Merrill, 2023) and benefits for automation di-
rected at improving SA (Cicchino, 2018).
This paper shows the robust effects of auto-
mation failures on human performance due to
automation confusion, SA and OOTL problems,
and automation interaction problems, with acci-
dents often stemming from multiple contributing
factors. Importantly, there are many interventions
that are available to break the accident chain, as
outlined in Figure 1. Automation developers and
organizations should focus on improving the de-
sign of the automation and the human-automation
interface, detailed testing of the combined human-
automation system in difficult and novel scenarios,
providing clear communications regarding system
capabilities and limitations, setting appropriate
policies, and providing needed training.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iD
Mica R. Endsley  https://orcid.org/0000-0002-2359-
947X
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Dr Endsley is president of SA Technologies and a
former Chief Scientist of the U.S. Air Force. She
has published over 200 articles on situation
awareness and the effects of AI and automation on
human performance. Dr. Endsley has a PhD in
Industrial & Systems Engineering from the Uni-
versity of Southern California and is a fellow and
former President of the Human Factors and Er-
gonomics Society.