Cognitive Ergonomics

Dr. Manish Kumar Asthana

Human Error-II

Hello everyone. Today I welcome you again in the lecture series of Cognitive Ergonomic. As
we were discussing about the topic human error, today I am going to take you forward in this
lecture series of human error. Now in the human error, in the previous lecture as we learned
about the types of error, we also learned about the intended and unintended error. What we
also were being discussing about when the human error and the occurrence of human error is
happening because of the person, the operator or the system. So, when the human error is
occurring because of the operator, then that need to be, that is the one side of the coin and the
other side of the coin is the system itself.

So human error problem can be seen in this two ways, person approach or the system approach.
Two sides of the same coin. First let us understand about the person approach. If we discuss,
if you see about the person approach, errors are occurring because of the apparent mental
processes such as forgetting information, inattention, poor motivation, carelessness,
negligence, recklessness, etc and etc.
That is why in the human error, earlier when the, in the ergonomics, when the human errors
were happening, we were not able to closely look into it why these human errors are occurring
and also, we were, initially we thought that maybe the system itself is not sufficient enough
providing aid to the person because of which this human error is happening. Another group
was there who was talking about the person itself is not capable enough, is skillful enough that
he or she may deal it with the system as well. So, such understanding at least was not so very
clear about it that the human cognition is an important role here. So, in a person approach
when we are talking about it, we understand mental processes, mental cognition, what kind of
cognition person is having, are they able to recollect, recall information at the time of need, are
they able to pay attention to the task when it is required, are they able to interpret the incoming
sensory information at the time.

If any failure occurs at any one of these cognitive processes, then the person is responsible
for it and the chances of human error is high. And this is what we have seen that lot of
ergonomic accidents, a lot of ergonomic incidents which has occurred is because of majorly it
is because of the human error, person's mental condition or mental processes happening.
Secondly, this approach also tends to treat errors as moral issues. So many a time when the
cases come up, these case studies are considered not only for the training purpose, but also
being seen as issues which people could have done to avoid and bad things has happened to
the bad people. Those bad people we are referring to those people who violate the rules, who
makes mistake intentionally and resulting into a human error.

So, psychologists have called just the world hypothesis and trying to understand what could
be the underlying cause. Psychologists in fact has paid little closer attention to such human
error as human beings are involved, what are their mental conditions, what is resulting into
such a sort of human behaviour. So, as we were discussing in the previous lecture,
inappropriate behaviour. So, psychologists are more interested into an understanding what is
the root cause of these inappropriate behaviours. If we understand these inappropriate
behaviours, then we may able to understand why the human beings are making such error.

And if there is a tendency which human beings are making such error, then such skill or
abilities should be addressed closely to avoid such human error. So, countermeasures if we are
talking about what kind of countermeasures one can take, so it could be post a campaign that
appeals to the people sense of fear. So, for instance, some sort of phobia is there in the society
that some sort of instigation is there, some sort of thought is there. During the time of pandemic
if you remember, lot of posters, poster campaigns people started to take the measures to avoid
the pandemic and those guidelines were being posted across the cities, across the public places,
so that people understand that what are the precautionary measures one can take to avoid such
conditions and to avoid the COVID. Then the writing another procedures or adding or existing
ones, so very soon we saw that from wave 1 of COVID-19 to wave 2 of COVID-19 to wave 3
of COVID-19, writing another procedures keep on modifying, people keep on adding more and
more layers of precautionary measures into it.

So, this we have seen and now in today's world there are still some speculation, there are still
some information related to the disease, but people are very much aware, people know what
kind of disciplinary measures need to be required in order to avoid the threat and how to restrain
ourselves, how to protect ourselves against such a pandemic situation. Now another thing is
that how one can also take countermeasures is naming, blaming or shaming game which is a
very common game and which is happening in last one century that people used to blame
somebody else that that person is responsible. So, when if we recall the Chernobyl incident
which happened in 1986, people started to blame Russia for each and everything, but then
Russians were blaming their engineers, engineers were blaming their operators that they were
not skillful enough to handle the nuclear power plant. But such blaming and shaming thing
which was going on, we have to understand that the secrecy actually resulted into such disaster,
secrecy or the lack of information which the operators were having, how to control the nuclear
reactor when there is an exothermic reaction, such lack of information resulted into such a big
disaster. So, such blaming and shaming things have been there to avoid the human error and
we have seen that such things need to be avoided in order to avoid the human error.
 So what we see, what you can see on your screen is that if we talk about the person approach,
so if there is a human error which is there resulting into an adverse event, then there is a blame
and then there is a shame condition and we also know that from this there are some assumptions
being drawn up and these assumptions are not the accurate or correct assumptions, but errors
are caused by inadequate skills, knowledge, inattention, clumsiness, laziness, negligence and
carelessness. People always tend to make such assumptions that if any, let us say you are
working on a computer system and your supervisor asks you to save a file, but instead of
pressing the control S button, you press control D button and then all or instead of saving the
file, you delete the file. Then this human error, your supervisor might consider it into, can have
an informed that he is inattentive, he is lazy or he is not paying more attention to his mind, his
mind is wandering, he is always doing such kind of activities and he is not sincere enough.
Now we have to understand that human error, when we are talking about it, what is the rate of
human error also? If that error rate is very high, then probably there is something which person
is responsible for it. However, if that rate is very, very less, then it may be a chance of error
one or two times it might occur.

Another assumption is the blaming and shaming and punishing the guilty one that okay, you
have been, you have caused or compromised a billion dollar system, we cannot do such, we
cannot tolerate such kind of activities. So, the easy solution is that you leave the firm, you
leave the organization so that we do not have to face the consequences in the near future, we
may tend to avoid such error by firing you. Many occasions such things happen and from day-
to-day life also we might have seen that if any human casualty happens, then the police
commissioner tries to fire their junior officers because of the error, because of late submission
of the report or not looking into the investigation thoroughly. So, such kind of examples we
have seen, we see from day-to-day life. So, when we are talking about such approach, this is
a person approach, this is one side of the coin, what is about the other side of the coin? What
people are, what the other end of the coin is suggesting us? The other side of the coin is the
system approach.

So human and system go hand in hand. As earlier we were talking about the human machine
interaction, human computer interaction, here system can be seen as machine or the system as
well. So, this other side of the coin is talking about that human has not make an error, but a
system is making an error, system is fallible, system is having a lot of errors. So, such thing
we need to have a clear understanding. So, this system approach also believes that the humans
are fallible and errors are to be expected.

It concentrates on the condition under which individuals work and tries to build defenses to
avert and mitigate their effects. So, what are the conditions, adverse conditions, the
documentation of those adverse conditions? What are the individuals are trying to build
defenses to avoid such conditions? That is something which system is talking about. How can
we make a system so robust so that the error can be avoided? Instead of blaming, this approach
is focused on identifying two causes of the error. What is the underlying cause of such error?
And building defenses to avoid such errors to happen again in the near future. So, defenses
within the system is required in which system work in order to anticipate and prevent the error.

So, when a person is working in a system, it can be seen as an organization or when a person
is working with the system, the system can be a computer system. So, what kind of defense
mechanism one could be building it? So let us say I was telling you an example about the
control S saving the file versus control delete, deleting the file. Now something which you
have worked upon last 4 hours writing a draft, writing a paper or writing a text, then you would
like to save this file. But instead of pressing the save file because you are being tired, you press
the delete file. Now if the system, there is no defense mechanism, then the moment you press
control D, then all the information which you noted down will go away.

To avoid such behavior, system comes up with some assistive feature. These assistive features
are one thing is that autosave option is there. The moment there is a sudden power cut, then
the system saves some information. The moment suddenly the system fails, then automatically
autosave system is there which saves the file. Now autosave option has a feature in it.

You can save the auto file in every 5 seconds, 10 seconds, every 5 minutes, 10 minutes or in
30 minutes or 1 hour. So, by default, automatically the file get saved and registered. Now by
mistake, if you are deleting the file instead of saving the file, then a pop-up menu comes appear
on the screen like okay, would you like to save the file, would you like to cancel the file or
would you like to delete the file. Now when you want to save the file, then you save the file
and you save it with the name so that you can recollect and recall it later. So, such things
human work is in order to anticipate and prevent the error, limit their impact when they occur.

Now the second point easily highlights that people build some defense mechanism in order to
counter the errors. So, countermeasures is opted in the under the system approach such as the
changing the condition under which human works. So, changing the human conditions, what
could be those conditions? One could change the context, one could change the positioning,
one could be on a rotation. So, a person does not sit and work with the same system for too
long because of the boredom, stress, anxiety, depression could come. Also, as I was telling
earlier about the other type of human emotional feelings start to emerge out.

When an adverse events occur, the important issue is not who blundered it, but how and when,
why it failed. So even when the let us say even after understanding such system and even after
understanding the factors which are playing role, when the incident occur, still no matter how
strong, robust, stringent system you make it, still the chances of human error is quite common.
And let us say the human error occurs, let us say adverse event occur, then the important issue
is not who has made that mistake because of whom the adverse event has occurred, but how
and why it failed actually, why the system has failed, such is an important question because if
we understand how and why it failed, then we can make the system more robust and we may
tend to avoid the human error. Such understanding also brings in deeper insight to us into us
about the system itself. So, if you see on your screen, this is unlucky instances are there where
one is feeling unlucky and then those things turn out.

So unlucky instances if you talk about, it could be seen as the Chernobyl incident because
people were unlucky, they lowered the fuel rod and then the fuel rod just started have an
exothermic reaction and it resulted into that. So, people were not very lucky about it. So those
individuals also the fire brigade people who came to extinguish the fire, but the fire due to
nuclear reactor is more lethal than the normal fires. There are different types of fires are there,
there are different type of fire extinguishers are there. This is what we have discussed earlier
also in our human skill and abilities lecture series about different types of fire extinguishers
were there and people have used it differently.

So, the fire due to nuclear power plant requires different approach actually. Lot of radiations
were there. So, at the time of extinguishing the fire, lot of fire workers just got radiation and
because of that they died within a week and few died within the same day also due to large
exposure of radiation. Some factors are hidden in nature that is the latent failures are there,
some factors hidden failures are there which means that we are not familiar with those factors.
So let us say if you talk about the Chernobyl incident again, then the operators were unaware
of the fact that when the fuel rod will be brought down, then it will catch fire or if you
remember previously we discussed about the, I showed you an example of Colombian shuttle
experiment that when the shuttle was taking off to the space, then a little foam thermocoil just
came out from the shuttle and when the Colombian shuttle entered into the earth atmosphere,
then it caught fire and compromising not only the billion dollar machine but also costing the
lives of the wonderful and great astronauts.

So, such latent failure because astronauts were not familiar, astronauts were not having any
insight about it that there is a missing thermocoil there which they later realized that there is
something wrong with the system, there is sudden increase in temperature in the shuttle and
which resulted into the failure and causing the life of the astronauts. Now in latent failure if
you talk about the root causes, blend in factors, what are those factors? Those factors are
hidden in nature and then the active failures. So, when we are talking about the system
approach, active failures we are familiar with this, it is explicit in nature. Latent failures are
implicit factors which we are not very much aware of it. Another is the active failure if you
talk about immediate causes are there, immediately direct cause and effect relationship is there,
one can easily understand this is the direct cause towards it and then the factors are more visible
to it.

So ineffective safety barrier is there, adverse event or near miss is there. So, you know these
factors at least resulting into the human error. So, system approach is talking about all these
aspects and one thing is very clear that having the two sides of the same coin, one understand
that system approach is not very independent part than the human approach system or human
approach system is not very independent from the system approach system. They go hand in
hand and that is why the human errors are happening or occurring. Now when we are talking
about the human error, it is very important for us to understand what is the human error cause
model.

Now this cause model if you see it closely, the reason for human error could be unsafe
psychological condition. So, person is not very safe in the environment, people are bullying
him. So, there could be an academic bullying, there could be a professional bullying and that
working in that environment for a brief period of time may not be that injurious to a person,
but working in that environment for too long, more than 6 months or 1 year can result into a
clinical problem. So, such working environment or working conditions can result into a human
error which is a common cause these days. So, work environment is an important part and
people have to ensure that psychological activities should be addressed.

Physiological factors, most of the time we have seen also the musculoskeletal injury, contact,
stress are common problem. Contact stress like when I am in contact with the pen, so this is a
contact and if too long I have to hold this pen that the pen will start stressing my fingers. As a
result this may alter my physiological responses altogether. Outside the environmental factors,
what are the other environmental factors outside it? So, this could be experiential, this could
be cognitive in nature, this could be also experiential in nature altogether. So, such factors are
there which is not entirely depend on the environment, in which environment the task is being
performed or executed.

Imperfect safety training and safety management which means that safety training and safety
management is very, very lousy. For instance, if we talk about the Bhopal gas tragedy where
the carbon carbide gas which is poisonous in nature, it started to leak at midnight and then it
caused severe damage in the Bhopal. Till date we see the imprints of carbon carbide and till
date we even see how much it has affected genetically and genetically altered or genetic
impairment in the human DNA itself is being noticed and observed in the recent past we have
seen. If you see closely, so the psychology seems should be an important part.

So, we talk about the insecure psychology. Why such insecurity is there? We will come to it
a little late. Physiological factors, skin temperature, heart rate, blood pressure, facial muscles,
all these physiological factors and also one could talk about the electrophysiological
parameters. What are the changes in the brain? Environmental factor in the working
environment conditions, what kind of working conditions you are working in? Is it good? Is
it bad? Is it helpful? Is it not helpful? Hostile? What kind of colleagues you are working with?
All those things actually come under this category. Safety training does not reach the
designated position. The purpose of safety training, the purpose of the training workshops is
that person get familiar with these systems, settings and may build some perfection towards
the safety management.
And finally, the safety management itself is very faulty in its nature. So, when safety
management is faulty, when safety training is not being done properly, when the environmental
factors are risky, when the physiological factor the person itself is having some limitation about
working condition and then the psychology of it. All together they result into a human error.
Any one of these factors or more can contribute to human error. And when there is a human
error, when there is an inappropriate behavior is there, this result into an accident.

And such aspects actually highlights the challenges. Now let us closely see, so as we were
discussing earlier insecure psychology, physiological factor, environmental factor, safety, let
us closely look into these factors. First let me talk to you about the insecure psychology.
Insecure psychology is having lot of psychological concepts and ideas which mainly refers to
the mental state of the employee and all these psychology or mental state of the employee
suggest the leading cause towards the accident and also the low safety awareness. So, if you
talk about the fluky psychology, small mistakes and errors, potential dangers can be forgiven
which means that small mistakes and errors are happening and potential dangers can be
forgiven, there is no such potential danger is there.

For instance, you turn off the computer system from the power button. When you turn off the
computers from the power button, there is an autosave system already there in your by default
in the MS Word or PowerPoint or Excel. So, the moment you do that system automatically
saves the file and you may avoid the potential danger towards it. Confirmative psychology, on
noticing people who break rules have not caused any accident. People who are breaking the
rules, there was an error which is happening because of the rules are not being followed, rule
based error.

So, on noticing people who break the rules have not caused any accident, else they start an
effort. Here we will follow the belief that errors would not happen again, so they do such thing.
The error can be avoided in such an instances. In Ignorant psychology, people are ignoring
about information. So, some workers do not have knowledge and skill on how to handle a
situation to ensure his own safety and control the accident in the smallest range.

So, people are not, they lack certain knowledge, they lack certain skills and abilities and they
are ignorant about it. Oh, we do not need such knowledge and understanding, it is worthless
and we do not have to pay too much attention towards this. So, when such ignorance is there,
it is compromising the safety and control of the system and as a result you know what happens,
the chances of human error increases. Then the rebellious psychology talks about the
psychological state to maintain self-esteem with each other. I know everything, I do not need
any help, I know how to control the system, I know how to lower the fuel rod, do not teach me
how to lower the fuel rod into the coolant chamber to lower the temperature, I know how, what
will happen when I have to connect the space shuttle to the international space station.
 Such kind of rebellious behaviour actually goes, does not go along with the other people. As
a result what happens, the chances of human error increases little bit. Crafty psychology, some
operators or workers want to finish their work in less time, so they are so crafty, they are so
speedy that certain rules, certain knowledge, certain safety concerns seem to be avoided in this
regard which may result in human error. Then sixth one is the inert psychology. Workers
engaged in a specific job, certain amount of time is required.

They do not pay attention to the job, new problem and situations. They just believe that oh, I
have a specific job to do, I just have to type the letter, I just have to prepare the file. But they
do not pay attention to the job, my current job, what is its demand, what is its need, what skills
do I have, what skills I do not have. So those elements they do not pay attention to, as a result
the chances of error may also occur in our psychology. Comparing psychology, some workers
in effort to prove that they are the best engaged in the some adequate behaviour, I am the best
one, I am better than him, I can handle the problem better than him, I can prepare the task better
than him.

Such comparing psychology, such comparing behaviours are also very, very dangerous at the
workplace setting and which may turn, which may lead towards the human error. Now talking
about the psychology, insecure psychology of the people, different type of people working in
the same workplace setting, we move towards the physiological factors. Physiological factors,
fatigue, fatigue is one of the important factors which causes human error. People feel fatigue,
boredom is there, distress is there, lot of work is required, they do not and they have to finish
a job in a specific period of time which increases the stress in them. Workers are sometimes
not suitable for the type of work they are engaged in, so they lack necessary skill.

So, when we talk about the physiological factor, then there is a biological factor related to it,
device qualitative factor, what kind of device or system they are interacting with, it is the nature
of it and then the fatigue factors are there. So, what is more important is that the physiological
factors which are playing role, skin temperature, heart rate variability and many other
physiological component to it. So, if you see closely, health issues, disease, employee position,
what kind of position an employee is having, physical, psychological factors. When we talk
about the biological factor, alertness, day and night, fatigue and sleepiness, so biological factor
if you all remember when I was talking to you about the human disaster, mostly these human
disasters occur at the midnight 1 to 3 or 4 pm, 1 to 3 am or 4 am in the morning. Why such
incidents are occurring? Because our circadian cycle, our biological cycles, according to our
biological cycle, we tend to prefer to sleep at night.

But when at night people are working, the chances of human error seems to be very high and
especially between these time period 1 to 3 am. Then the fatigue factor, boredom, tension is
there, concentration, lack of concentration is seen, rejection is also been seen, people
sometimes being felt rejected, paralysis is also there, too long you are sitting on a chair, your
legs seems to be jammed, too long you are in a standing position, your legs seems to be jammed
as well. So, and then the sense of the safety itself, what kind of safety I am having. And
musculoskeletal injury, that is why in human factor is very, very common because person has
to take one position and continue take that position for a long period of time. That is why
contact stress is also one leading cause towards the arthritis these days in the workplace setting.

The environmental factors talk about the work environment such as the high intensity noises,
unweighted places, bad lightning, if the light is very less in nature, person has to put lot of
effort in understanding what is written, what has to be written, high temperature is there, high
humidity is there, exposure to dust, poison, etc. Now such factors actually each individual has
its own physiological limitations. Everything in this environmental condition can affect their
physiology, as a result it turned out to affect their performance, efficiency and safety concerns.
Such conditions differently affect the employees, psychological, physiological as we were
talking about it, it makes worker agitated, irritable, unstable emotions are there.

Many occasions people seem to outburst. So, there is an internal environmental factor, there
is an external environmental factor which makes the environment safe and then there is a family
environmental factor, weak safety culture, these are implicit factors. Generally, we do not
discuss these factors at the workplace setting and these factors are unsafe in nature. Now both
these factors are safe, one way or the other, one is safe, another is unsafe, they go hand in hand
and resulting into this human error. So then how much safety training is being provided, more
and more safety training is provided to the person, more necessary operational skill is there, so
a person can avoid the human error, the chances of error will be reduced. If the worker did not
take that training seriously, then the chances of error will be very high.

Safety management is very poor, for example, organization does not formulate the safety
system at all. The system is not adequate, enforcement is also inefficient. How to build the
safety management, how to make the principle more reinforced, how can we make people learn
about the safety measures, when we have a regular training, when we have a regular workshops
on it, then we can make the system more and more stringent and robust in nature. This is the
aspect when we are talking about such elements, we have to also understand are we able to
detect the errors. So, errors do not necessarily lead to the harm if they are discovered quickly.

So, if you detect the error prior hand, we may come to the countermeasure to it, we can avoid
such errors. The different categories of errors are already there, so we know that there is a slip,
there is lapses, one is action based, one is memory lapse, knowledge based, rule based, such
errors are there and if one is coming to know beforehand, then we may tend to avoid such
errors. So, detection is actually, detecting the error actually is a win situation. One can not
only avoid the errors, but can also come up with the countermeasures towards it.

So, memory lapse slips are different to detect precisely. Some errors are very difficult to
detect, so such as the memory lapse, memory lapse slips are difficult to detect precisely, why?
Because there is nothing to see, nothing you can see, you cannot see how much information I
am retrieving, you cannot see how much information I am recollecting, recognizing, such
things we are not able to see. As a result, it becomes very difficult for us to detect the errors.
With the memory slip, the required action is not performed, certain actions is required, but
cannot be performed. It is only the lack of action allows some unwanted events to occur.

So, there is a hope for detecting a memory lapse slip. There is a hope that in coming years,
we may come up with a mechanism, we may come up with a measure where one could be
easily able to detect the memory lapse. Mistakes are difficult to detect because there is anything
that can signal an inappropriate goal. So, mistakes also when we were talking about it, then
we understood that it could be knowledge based, rule based or memory lapse. So similarly,
like the memory lapse condition, mistake can also not be detected. What we learn in this
lecture, today's lecture in the human error is that how are we managing this error and while
managing the error, there can be a person and system approach both.

So, both person and system approach, both are actually two sides of the same coin. So, one
end we are trying to understand the person's failure, another end we are trying to understand
can we make a system so robust, so stringent, so rigid that such mistakes can be avoided. We
also saw that, also learned about the human error cost model where we talked about the insecure
psychology, physiological factor, environmental factor. In addition to safety training and skill
and how these safety training and skills are not being trained or provided, then lead towards
the human error.

And finally, we ended up with the detecting of the error. How well are we able to detect the
error? If we are able to detect the error, then we can tend to avoid the error prior hand, we can
come up with the countermeasures prior hand. As a result, the human error can be avoided and
lot of things could be saved in this regard. Human performance, efficiency and safety violation
can be considered as well. So, I would like to say thank you here and we will start our next
lecture from the Swiss cheese model and further topics in line. Thank you. Thank you.