Human Error:

1. Human Error: Perennial and Pervasive A Presentation at the Human Factors and Ergonomics Society 8th San Diego Chapter Symposium March 8, 2003 George Edw. Seymour, Ph.D. Space & Naval Warfare Center, San Diego

2. Quotes: • “Anyone can make mistakes, but only an idiot persists in his error.” Cicero, 44 B.C. • “Sometimes we may learn more from a man's errors, than from his virtues.” Henry Wadsworth Longfellow • “Every great mistake has a halfway moment, a split second when it can be recalled and perhaps remedied.” Pearl S. Buck • “I have learned as a composer chiefly through my mistakes and pursuits of false assumptions not by my exposure to fonts of wisdom and knowledge.” Igor Stravinsky • The “third leading cause of death in the United States are fatal mistakes that occur as a result of the misuse of the extraordinary medical technologies that we now have available. These accidents are responsible for over 400,000 deaths yearly---more than tobacco, stroke, diet, alcohol, drugs, firearms, or automobiles…” David Lawrence, 1999 March 8, 2003

3. Human Error: Agenda • Objectives • What is an Accident, an Error? • Extreme HO: Locus of Analysis • Methods of Error Analysis • The Problem: {World} {Nation} {Navy} • Visual Examples of Human Error • Recent Estimates of Human Error • Practical (and Scientific) Views • Hyperlinked References & Recent Books March 8, 2003

4. Objectives: My Objectives Today are to: • Spotlight & Focus on Error in Human Factors, • Focus on “Critical” HF Error Topics, i.e., Inverse Power Law, • Survey Recent HF Error Topics, and • Provide a Useful HF-related Resource Document. March 8, 2003

5. Soal's Experiments The Cat-Rat Ranch The Indian Rope Trick The Invasion From Mars The Seattle Pitted- Windshield Epidemic The Secret Life of Plants The Spanish Prisoner Tulip Mania, etc. Abram's Box Animal - Magnetism Chernobyl Clever Hans Crystal Power Discovery of the Planet Vulcan Graphology Keely's Motor Mania Martian Canals N-Rays Paranormal Metal Bending Phrenology Piltdown Man Polywater Psychic Surgery Pyramid Power Not Covered Today During August 17-21, 1995 at the University of Oregon, a group of assembled scholars discussed the topic of “human error” that included: March 8, 2003

6. “Honest Mistake” or “Big Mistake” “Two months after a double bypass heart operation that was supposed to save his life, comedian and former Saturday Night Live cast member Dana Carvey got some disheartening news: the cardiac surgeon had bypassed the wrong artery. It took another emergency operation to clear the blockage that was threatening to kill the 45-year-old funnyman and father of two young kids.” “Responding to a $7.5 million lawsuit Carvey brought against him, the surgeon said he'd made an honest mistake because Carvey's artery was unusually situated in his heart. But Carvey didn't see it that way: "It's like removing the wrong kidney. It's that big a mistake," the entertainer told People magazine..” March 8, 2003

7. What is an Accident, an Error? • “There is no consensus in the literature what constitutes an ‘accident’. Unplannedness and undesirability are more or less universal features of both dictionary definitions and the few references pausing to elucidate a definition” (Woodcock, 1989). • By definition, “accidental deaths are usually unforeseen, violent, and unexpected” (Webster 1986). • By definition, error is: “Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim; the accumulation of errors results in accidents” (Kohn et al 2000). March 8, 2003

8. Extreme Ho: Locus of Effort User Focus: p(E) = f(P + T + O) P = personnel selection, T = training, procedures, and O = organizational policies Environment Focus: p(E) = f(D + H + C) D = defective design, H = human computer interface, and C = task complexity } or { Manufacturers & Media vs. FDA & Six-Sigma March 8, 2003

9. Methods of Error Analysis • Apex • Critical Incident Technique • Events & Causal Factors Analysis • Failure Mode and Effects Analysis • Fault-Tree Analysis • Force Field Analysis • Human Reliability Analysis • MIL STDs: e.g., 1629A • Pareto Analysis • Poka Yoke • Probabilistic Risk Appraisal • Root Cause Analysis March 8, 2003

10. “Error” in the Published Literature Human Factors Publications: (key word) Source & Search Range / Data Range / Number • Human Factors: 1958 - 2001 1964 - 2000 20 • Ergonomics in Design 1993 - 2001 1994 - 1997 3 • Annual Proceedings 1972 - 2001 1972 - 2001 111 March 8, 2003

11. The Problem: In The World “On the evening of October 2nd, 1996, an AeroPeru Boeing 757, flight 603, with 61 passengers and 9 crewmembers, took off from Lima, Peru... All nine crew members and 61 passengers lost their lives ” Vigilant & Williamson (2002). “July 25, 2000, a small piece of debris on the runway at a Paris airport caused a tire to blow out on an Air France Concorde during its take off. A heavy slab of rubber that spun off from a tire created a shock wave in a wing tank, which burst open and sent fuel streaming into an engine intake. As flames trailed two hundred feet behind, the aircraft rolled out of control. The crash killed all 109 people on board and 4 more on the ground.” Chiles (2001). March 8, 2003

12. The Problem: In The Nation • Accidents are the fifth leading cause of death in the U.S. ( > 95.500 in 2000) (Vigilant & Williamson, 2002) • In 1995 “2,900 children died in motor vehicle crashes, 950 children drowned, more than 1,000 died from fire and burns,” plus 200 accidental gun deaths (NCPA, 1997). • In 2001: Number of unintentional deaths: 98,000. “The highest death total was 116,385 in 1969 and the lowest recent death total was 86,777 in 1992 (lowest since 1924). Unintentional injury deaths were up 2% in 2001 compared to 2000 A fatal injury occurs every 5 minutes and a disabling injury occurs every 1.5 seconds. Wage losses, medical expenses, property damage, employer costs, fire losses and other expenses related to unintentional injuries and fatalities cost Americans an estimated $516.9 billion in 2001. That's equal to about 52 cents of every dollar spent on food in the United States.” (National Safety Council, 2001). March 8, 2003

13. Most Dangerous Jobs: U.S. What is the Correct Rank Order? • Construction • Fishing • Logging • Mining and drilling • Piloting small aircraft • Roofing • Steel working • Truck driving March 8, 2003

14. Most Dangerous Jobs: U.S. This is the Correct Rank Order: • Logging (122.1 deaths per 100,000 workers) • Fishing • Piloting small aircraft • Steel working • Mining and drilling • Roofing • Construction • Truck driving The death rate for “astronauts and cosmonauts over the past 40+ years is (as of 02/03) about 7.5%, or 7,500 per 100,000 -- something like sixty times the rate for loggers.” March 8, 2003

15. Deaths Traffic 624 Afloat 19 Shore/ Ground/OpMV 134 Recreation 141 Aviation 155 Total Deaths: 1,076 The Problem: In The Navy “In the last five years (FY97-02), mishaps cost the Navy $4 BILLION and 1,076 LIVES!” “175 Sailors and Marines died in FY01” (Turcotte, 2002) March 8, 2003

16. Human Error, USN/USMC FY97-02 No. of Class-A Mishaps Human Error Navy/Marine Aviation* 138 of 170 HE 81% *FY97-01 F/FR/AGM HE 82% Navy Afloat 41 of 50 HE 75% Navy Operational Shore 36 of 48 HE 84% 295 of 350 Navy PMV FY02: 27 March March 8, 2003

17. Example 1: Hay Scaffold Someone “stacked bales of hay to make a very unstable scaffold. This “hay stack” was so wobbly that it had to be propped up with boards to keep it from falling.” This and subsequent examples from the Naval Safety Center (2003) March 8, 2003

18. Example 2: Popped Corn “The label on the bag says to never pop unattended but I always figured that was lawyer-speak since I've never heard of a problem, and besides, I have a routine. I put the bag in, press the 2 minute button and go to the shower after my lunch hour workout….” March 8, 2003

19. Example 3: Truck The “thing about static electricity is, some environments are more spark-worthy than others. You know, like when you walk on carpet in socks, or rub a balloon on your frizzy hair, or when you get out of your car (especially in the winter-time). If you're going to be around combustible material ... think!” March 8, 2003

20. Example 4: Pool Ladder “This prime example of human ingenuity shows a man standing barefoot on a metal ladder in a swimming pool with an electric drill held loosely in his hands...the plug gingerly tied and dangling next to his dripping wet, half soaked torso. You have to give him credit though...at least he's wearing safety goggles.” March 8, 2003

21. Example 5: Candles “The liquefied whatever it is gets real hot in those holders. They have been known to flare up, spill and splatter. Even worse, some gel candle holders have been reported to shatter and spew hot gel all over.” We all know about candles, right? Wrong! “That's exactly what happened to this young lady. A burning gel candle "exploded" and hot gel covered her hand. This photo was taken three weeks after the incident. She has no feeling and may require surgery to get her hand working properly again.” March 8, 2003

22. Recent Estimates of Human Error • APA Journal Abstracts: 8% - 18% (Harris, et al, 2002) • DNA: 1 in 267 (Kay, 2000) • Engineering: .003 (during construction) • Eyewitness: 34% - 60% (Saliba, 2000; Visual Expert, 2001) • Fingerprints: 20% - 50% (Berry, 2002; Harris, 2001) • Human Factors Research: .05 • Medical: 1 in 25 - 1 in 200 (Kogan, 2000; Maddox, 1997; Woods, 2003) • Power Stations: 20% (CRIEPI) • Software: 10% - 15% (Mann, 2002) • Voting systems: 1.6% - 6% March 8, 2003

23. Practical (and Scientific) Views • Source of Failures (is not less careful people). • Safety is “built-in” (but change & goal pressures). • Organizational success is not about avoided risks or reduced errors; rather it’s “creating safety by anticipating and planning for unexpected events and future surprises.” • Individual success is not about Hindsight Bias (blocks learning process); rather “begins with each of us being willing to question our beliefs to learn surprising things about how we can contribute to the potential for failure in a changing and limited resource world.” (Woods, 2003) March 8, 2003

24. Sound Familiar? Consider: • Creative adjustment to current “problem” (hay stack) • Ignoring advice, directions, or rules (gas, popcorn, pool ladder) • False knowledge transference (candle) • Misjudgments during dual processing (cell phone or distractions while driving) • Admitting errors is an organizational function (Edmondson, 2002) • Causal inference errors (Hannigan & Reinitz, 2001) March 8, 2003

25. Hyperlinked Resources: I • American Iatrogenic Association (2003). Medical Error: 1988-2000. • Berry, S. (2002). Pointing a Finger at Prints. LA Times • Casey, S. (1998). Set Phasers on Stun and Other True Tales of Design, Technology, and Human Error. Aegean. • Central Research Institute of Electric Power Industry (CRIEPI). What is Human Factors Education. • Chiles, J.R. (2001). Inviting Disaster. Harper Collins. • Covello, V. and P. Sandman. (2001). Risk communication: Evolution and Revolution. in Wolbarst A. (ed.) Solutions to an Environment in Peril. Baltimore, MD: John Hopkins University Press (164-178) • Edmondson, A. (2002), Learning Curve: How to Turn Mistakes Into Knowledge. Harvard Business School Reports. • Engelke, C. & Olivier, D. (2002). Putting Human Factors Engineering into Practice. Medical Device & Diagnostic Industry. • Grabowski, M. & Roberts, K. (1998). Risk Mitigation in Virtual Organizations. Journal of Computer Mediated Communication. • Grout, J. (2002 ). Glossary of Error-Proofing Terms. • Gudzyk, K. (2001). Umbrella Against Mistakes. The Day. March 8, 2003

26. Hyperlinked Resources: II • Hannigan, A.L. & Reinitz, M.T. (2001). A Demonstration and Comparison of Two Types of Inference-Based Memory Errors. Journal of Experimental Psychology. • Harris, D. (2001). Smudged Prints: Experts Question the Authority of Fingerprint Analysis. ABC News. • Harris A, Standard S, Brunning J, Casey S, Goldberg J, Oliver L,Ito K, Marshall J. (2002). The Accuracy of Abstracts in Psychology Journals. Journal of Psychology, March  v. 136  no. 2  p. 141-8 • Johnson, C. (2002). Accident Analysis & Safety Links. • Kay, L.I. (2000). DNA Statistics Found Insufficient… Forensic Evidence. • Kogan, M. (2000). Human factors viewed as key to reducing medical errors. APA Monitor. • Kohn, T., Corrigan, J. & Donaldson, M. (Eds.) (2000). To Err is Human. National Academies Press. • Maddox, M. (1997). Designing Medical Devices to Minimize Human Error. Medical Device & Diagnostic. • Mann, C. (2002). Why software is so bad ... Technology & Science March 8, 2003

27. Hyperlinked Resources: III • National Center for Policy Analysis (NCPA) (1997). "Childproofing" America. • National Safety Council (2001). Report on Injuries in America, 2001. • Naval Safety Center (2003): Hay scaffold Popped Corn  Truck  Pool Ladder  Candles • Papanek, V. (1973). Design for the Real World. Bantam. • Saliba, C. (2000). Eye of the Beholder. RCN. • Turcotte, S. (2002). Joint Service Safety Conference. April 4. • Ultimate Crash Site: Crash Video Archive. • Vigilant, L. & Williamson, J. (2002). To Die by Mistake: Accidental Deaths. • Visual Expert (2001). Errors in Eyewitness Identification Procedures. • Woodcock, K. (1989). Accidents and Injuries and Ergonomics: A review of theory and practice. Proceedings of the Annual Conference of the Human Factors Association of Canada, 1–10. • Woods, D. (2003). Behind Human Error: Human Factors Research to Improve Patient Safety. APA (Monitor) March 8, 2003

28. Set Phasers on Stun 1998 Normal Accidents 1999 Recent Books of Interest Logic of Failure 1996 Managing the Risks of Organizational Accidents 1997 The Limits of Safety 1995 Human Error 1990 Inviting Disaster 2001 March 8, 2003