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Risk, Human Error, and System Resilience: Fundamental Ideas
Thomas B. Sheridan
DoT Volpe National Transportation Systems Center, Cambridge, MA, sheridan{at}volpe.dot.gov
Objective: I review and critique basic ideas of both traditional error/risk analysis and the newer and contrasting paradigm of resilience engineering. Background: Analysis of human error has matured and been applied over the past 50 years by human factors engineers, whereas the resilience engineering paradigm is relatively new. Method: Fundamental ideas and examples of human factors applications of each approach are presented and contrasted. Results: Probabilistic risk analysis provides mathematical rigor in generalizing on past error events to identify system vulnerabilities, but prediction is problematical because (a) error definition is arbitrary, and thus it is difficult to infer valid probabilities of human error to input to quantitative models, and (b) future accident conditions are likely to be quite different from those of past accidents. The new resilience engineering paradigm, in contrast, is oriented toward organizational process and is concerned with anticipating, mitigating, and preparing for graceful recovery from future events. Conclusion: Resilience engineering complements traditional error analysis but has yet to provide useful quantification and operational methods. Application: A best safety strategy is to use both approaches.
References
- Baker, D.P., & Krokos, K.J. (2007). Development and validation of aviation causal contributors for error reporting systems (ACCERS). Human Factors, 49, 185-199.[Abstract/Free Full Text]
- Barach, P., & Small, S.D. (2000). Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. British Medical Journal, 320, 759-763.[Free Full Text]
- Danaher, J.W. (1980). Human error inATC system operations. Human Factors, 22, 535-545.
- Dekker, S. (2007). Doctors are more dangerous than gun owners: A rejoinder to error counting. Human Factors, 49, 177-184.[Abstract/Free Full Text]
- Evans, L. (1991). Traffic safety and the driver. New York: Van Nostrand Reinhold.
- Gaba, D.M., Singer, S.J., Sinaiko, A.D., Bowen, J.D., & Ciavarelli, A.P. (2003). Differences in safety climate between hospital personnel and naval aviators. Human Factors, 45, 173-185.[Medline]
[Order article via Infotrieve]
- Gertman, D.I., & Blackman, H.S. (1994). Human reliability and safety analysis data handbook. New York: Wiley.
- Gertman, D., Byers, J., Blackman, H., Hanley, L., Smith, C., Marble, J., et al. (2003). SPAR-H method (INEEL/EXT-02-10307). Idaho Falls: Idaho National Engineering and Environmental Laboratory.
- Hall, R.E., Samanta, P.K., & Swoboda, A.L. (1981). Sensitivity of risk parameters to human errors in reactor safety study for a PWR (Brookhaven National Lab Rep. 51322/ NUREG CR 1979). Washington, DC: Nuclear Regulatory Commission.
- Heinrich, H.W. (1931). Industrial accident prevention. New York: McGraw-Hill.
- Holden, R.J., & Karsh, B.-T. (2007). A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Human Factors, 49, 257-276.[Abstract/Free Full Text]
- Hollnagel, E. (1998). Cognitive reliability and error analysis method (CREAM). New York: Elsevier Science.
- Hollnagel, E., & Rigaud, E. (Eds.). (2006). Proceedings of the Second Resilience Engineering Symposium. Montréal, Quebec, Canada: Presses Internationales Polytechnique.
- Hollnagel, E., Woods, D.D., & Leveson, N. (2006). Resilience engineering: Concepts and precepts. Burlington, VT: Ashgate.
- Hunter, D.R. (2001). Retrospective and prospective validity of aircraft accident risk indicators. Human Factors, 43, 509-518.[CrossRef][Medline]
[Order article via Infotrieve]
- Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press.
- Leape, L. (1994). Error in medicine. Journal of the American Medical Association, 21, 272.
- Lee, J.D. (2006). Driving safety. In R. Nickerson (Ed.), Reviews of human factors and ergonomics (Vol. 1, pp. 219-253). Santa Monica, CA: Human Factors and Ergonomics Society.
- Marais, K., & Leveson, N. (2003). Archetypes for organisational safety. In Proceedings of the Second Workshop on the Investigation and Reporting of Incidents and Accidents (IRIA 2003), NASA/CP-2003-212642. Retrieved December 12, 2007, from http://shemesh.larc.nasa.gov/iria03/p01-marais.pdf
- Morrow, D., North, R., & Wickens, C.D. (2006). Reducing and mitigating human error in medicine. In R. Nickerson (Ed.), Reviews of human factors and ergonomics (Vol. 1, pp. 254-296). Santa Monica, CA: Human Factors and Ergonomics Society.
- Pew, R. W., & Mavor, A. S. (Eds.). (2007). Human-system integration in the development process: A new look. Washington, DC: National Academy Press.
- Rasmussen, J., & Pedersen, O.M. (1984). Human factors in probabilistic risk analysis and risk management. In Operational safety of nuclear power plants (Vol. 1). Vienna: InternationalAtomic Energy Agency.
- Reason, J. (1990). Human error. Cambridge, UK: Cambridge University Press.
- Reason, J. (1997). Managing the risks of organizational accidents. Burlington, VT: Ashgate.
- Reason, J., Hollnagel, E., & Paries, J. (2006). Revisiting the Swiss cheese model of accidents (EUROCONTROL EEC Note No. 13/06). Brétigny-sur-Orge Cedex, France: EUROCONTROL Experimental Centre. Retrieved December 12, 2007, from http://www.eurocontrol.int/eec/gallery/content/public/documents/EEC_notes/2006/EEC_note_2006_13.pdf
- Senders, J.W., & Moray, N.P. (1991). Human error: Cause, prediction and reduction. Mahwah, NJ: Erlbaum.
- Shappell, S., Detwiler, C., Halcomb, K., Hackworth, C., Boquet, A., & Wiegmann, D. (2007). Human error and commercial aviation accidents: An analysis using the Human Factors Analysis and Classification System. Human Factors, 49, 227-242.[Abstract/Free Full Text]
- Sheridan, T.B. (1992). Telerobotics, automation and human supervisory control. Cambridge, MA: MIT Press.
- Sheridan, T.B., & Ferrell, W.R. (1974). Man-machine systems. Cambridge, MA: MIT Press.
- Skinner, B.F. (1953). Science and human behavior. New York: Free Press.
- Swain, A.D., & Guttman, H.E. (1983). Handbook of human reliability analysis with emphasis on nuclear power plant applications (Sandia National Labs NUREG CR-1278). Washington, DC: Nuclear Regulatory Commission.
- U.S. Nuclear Regulatory Commission. (2000). Technical basis and implementation guidelines for a technique for human event analysis (ATHEANA) (NUREG-1624, Rev. 1). Rockville, MD: Author.
- Von Neumann, J., & Morganstern, O. (1944). Theory of games and economic behavior. Princeton, NJ: Princeton University Press.
- Wiegmann, D.A., & Shappell, S. (2003). A human error approach to aviation accident analysis and classification system. Burlington, VT: Ashgate.
- Wilson, K.A., Salas, E., Priest, H.A., &Andrews, D. (2007). Errors in the heat of battle: Taking a closer look at shared cognition breakdowns through teamwork. Human Factors, 49, 243-256.[Abstract/Free Full Text]
- Woods, D.D. (2006). Resilience engineering: Redefining the culture of safety and risk management. Human Factors and Ergonomics Society Bulletin, 49(12), 1-3.
Human Factors: The Journal of the Human Factors and Ergonomics Society, Vol. 50, No. 3,
418-426 (2008)
DOI: 10.1518/001872008X250773

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