04

Innovation management
Modul ke:

Human Error

Fakultas
Teknik JACKY CHIN

Program Studi
Magister Teknik
Industri
DEFINING HUMAN ERROR

• Any unwanted consequences resulting from

unplanned actions
STRUCTURE OF HUMAN ERROR
ERROR TAXONOMIES &
PREDICTING HUMAN ERROR
• Used to gather data to find weakness in
design, training, and operation
• Used with detailed analyses of tasks and
context to predict possible error and
countermeasures for detecting, minimizing,
and eliminating these error
• Characterizing all observable ways that a
task can be performed incorrectly
• Identify component’s failure cause and effect
ERROR TAXONOMIES

• Simple error taxonomy: differentiates error of

omission (forgetting), commission (doing
incorrectly)
• Commission error categorized to:
 Sequence error, doing an activity in wrong order
 Timing error: actions that do not occur when
required (done faster or delayed)
 Substitution error: wrong action performed
 Error involving intrusion: additional actions that
disrupting planned sequence of actions
TASK ANALYSIS
• Describes human’s involvement with a system in terms of
requirements, actions, and cognitive processes. Used to
understand and predict errors
• Provide broad overview of task requirements/detailed
description of activities (time, sequence, alternative,
contingencies, feedback, description)
• Relevant questions for creating TA:
– What kinds of actions by people that possible to
constitute errors?
– What are the possible consequences of these errors?
– What kinds of barriers do these errors and their
consequences call for?
PREDICTING EXTERNAL
ERROR MODELS

• TA can be used to predicting external error modes:

– To more underlying psychological mechanism
– Allowing similar errors to be distinguished
– Adding depth in understanding potential errors

• Example: Human Error Identification In System Technique

(HEIST)
HEIST
• HEIST classifies external error modes according 8 stages of
human processing by Kirwan in previous slides
• For HEIST code column, first is initial letter refers to one of
8 stages. Second letter is one of six general PSF: Time,
Interface, Experience, Procedure, task Organization, task
Complexity. Third one is numbering. (e.g. AT1: Activation
Time 1)
Code Error- External Error System Cause/ Error reduction guidelines
Identifier Mode Psychological
Prompt Error-Mechanism

AT1 Does the signal Action omitted or Signal timing Alter system configuration to
occur at performed either deficiency, failure of present signal appropriately;
appropriate too early or too prospective Repeat signal until action
time? late memory occurred
HEIST

• Psychological Error Mechanism (PEM): Possible

psychological error causing the external error
modes in HEIST. Further explained in different
table
• Example:
– Activation/Detection
• Cognitive/stimulus overload: Too many signals
present for the operator to cope with. Solve with
simplifications of signals, simulator training
• Signal unreliable: Operator treats signal as false due
to its unreliability. Solve with improved signal
reliability, increased level of tolerance on system
QUANTIFYING HUMAN ERROR
• Human Error Probability (HEP): Ratio of the number of
observed occurrences of the error to the number of
opportunities for that error to occur.
• HEP created because of the mandate for industries in high-
hazard operations to perform Probabilistic Risk Analyses
(PRA) (e.g. chemical processing and nuclear power
industries).
• Two primary hazard analysis techniques for PRA are Fault
Tree (FT) analysis and Event Tree (ET) analysis.
• FT utilize Boolean logic models to depict relationships
among hardware, human, and environmental events that
can lead to the undesirable top events.
QUANTIFYING HUMAN ERROR
• When using FT as a quantitative method, basic events
(events which no further analysis of the cause is carried
out) are propagated into a probability associated with the
top event
• As qualitative analysis tool, FT can identify various
combinations of events that could lead to the top event
• ET is an inductive analysis that determines how an
undesirable event can propagate. Capable of depicting
various sequence of events that can be triggered by the
initiating event and the risks associated
• In many PRA applications, FT and ET are combined. ET
represent a top event whose failure probability can be
computed through the evaluation of a corresponding FT
model
THERP
• Technique for Human Error Rate Prediction generally
referred as THERP
• Driven by decomposition: Human tasks first decomposed
into separable action or subtask. HEP then assigned to each
action. HEP then aggregated to derive probabilities of task
failure, which reflect human reliability
• Steps of THERP:
– Establishing which work will require attention, time,
skill, and concern for human error
– Assign HEP to each limbs of the tree corresponding to
incorrect performance and adjust as needed
– Compute success and failure probabilities for entire task
THERP
• Absence of existing hard data from the
operations of interest will require the HEP to
be derived from other sources, such as:
– Expert judgement such as direct numerical
estimation of paired comparison
– Simulators
– Data from jobs similar in psychological content
SLIM-MAUD
• Success Likelihood Index Methodology Multi-attribute
Utility Decomposition (SLIM-MAUD) represents another
procedure for deriving HEP
• SLIM allows analyst to focus on any human action or task
and provide inputs into PRA at various system levels
• SLIM assumes the probability that a human will carry out a
task successfully depends on the combined effects of some
relevant PSF
• For each action under considerations, experts required to
identify relevant set of PSF, assess each PSF with relative
importance (weights), rate how good each PSF is
SLIM-MAUD
• Weight for the PSF are derived by asking analyst to assign a
weight of 100 to the most important PSF, and then assign
weights ranging from 0 to 100 to the remaining PSF relative
to the one with value of 100. Normalized weights are
derived by dividing each weight by the sum of the weights
• Low weight indicate the PSF is unlikely to be under real
condition
• High weight indicate the PSF is likely to promote successful
task performance
• Summing normalized weight of each PSF resulting in scale
of success likelihood (SLI)
Terima Kasih
JACKY CHIN