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Human Factors Course Session 1

Human Factors Course Session 1. 2007 March 28. Eric Davey Crew Systems Solutions. Incident 1. NASA POES Spacecraft - Anomaly. Incident 1. NASA POES Spacecraft - Anomaly. Incident 1. Accident Findings. Causal Factors Procedural Compliance

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Human Factors Course Session 1

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  1. Human Factors CourseSession 1 2007 March 28 Eric Davey Crew Systems Solutions

  2. Incident 1 NASA POES Spacecraft - Anomaly

  3. Incident 1 NASA POES Spacecraft - Anomaly

  4. Incident 1 Accident Findings • Causal Factors • Procedural Compliance • Sept 04 - Crew 1 - Bolt removal without documentation • Sept 06 - Crew 2 - Cart use without verifying configuration • Consequences • Launch delay ~ 2 years • Significant rework and retest

  5. Incident 1 Other Possible Accident Factors • Design • Spacecraft configuration - Tall • Workplace - Service or transport • Tools - Bolt visibility and interlocks • Operations and Organizational • Independent verification • Tag-out on configuration changes • Shift change or work resumption practice • Time - Saturday following supper • Staffing - Numbers and experience

  6. Incident 2 American Airlines Flight 587 • Incident • 2001 November • Airbus 300-600 departing New York for Puerto Rico • Encounters wake turbulence on takeoff • Tail/rudder failure and separation • Loss of control • Consequence • 265 lives lost

  7. Incident 2 American Airlines Flight 587 • Headline Chronology • 2002 Feb • CBS Dangerous Rudder Movements • 2004 Oct • BBC Queens crash blamed on co-pilot • Globe Pilot error blamed in US Airbus crash • CNN NTSB: Copilot error caused 2001 crash

  8. Incident 2 American Airlines Flight 587 • Causal Factors • Environment Departure scheduling - turbulence Uncertainty in turbulence location Climb-out - High airspeed and airframe load • Training Response to wake turbulence Roll recovery with aggressive rudder use • Design Rudder sensitivity - full deflection A300-600 32 lb and 1.2 in travel Other Planes 125 lb and 4.0 in travel • Communication Breakdown between designer & airline

  9. Incident 3 Patient Hospital Safety - Canada • Adverse Event Study - 2000 • AE - Unintended patient injury by medical system Incidence (People/Year) Impact Incidence (Per 100 Admissions) Adverse Event 7.5 185,000 Preventable AE 2.8 70,000 AE - Death 1.5 37,000 Preventable AE - Death 0.66 16,000

  10. Incident 3 Patient Hospital Safety - Canada • Types of Complications • Wrong medication or dosage 1 in 9 • Infection • Adverse drug reaction • Hospital acquired injury • Consequences • 1.1 million added days in hospital/year ~$750 million • Patient and family inconvenience • Lost work time

  11. Incident 3 Problems with Medication Abbreviations • Common Misinterpretations Misinterpretation Abbreviation Meaning µg microgram mg - milligram qn nightly qh - hourly q1d daily q.i.d. - four times daily HS half strength hs - bedtime IJ injection IV - intravenous

  12. About this Course Introduction • Subject • Application of human factors criteria and methods in design to support users to achieve effective and error free performance • Context • Facility design, training & operations • Outcomes • Operational effectiveness Safety

  13. Introduction Course Structure • Four Sessions • Issues with human-systems operation • Break • Understanding human capabilities and performance • Lunch • Designing to support human-system interaction • Break • Applying human factors - Group exercise

  14. Introduction Eric Davey • Education • Electrical Engineering - Toronto & New Brunswick • Experience • Applied Nuclear R/D - Instrumentation & Systems - 15 years - AECL Chalk River • Power Reactor Control Rooms & Operations - 15 years • Projects - Human Factors • Task characterization and analysis • Workspace design • Systems development - Annunciation and Displays • Operations assessment - Changes • Regulatory compliance

  15. Introduction Session 1 - Issues with human-systems operation • Topics • Incident examples • Course purpose & content • Supporting human performance • Symptoms of problems • Range of factors • Approaches • What is human factors? • Examples of assessing/providing task support

  16. Background Symptoms - Lack of Support • User’s View • What is it doing now? • Why did it do that? • How did I get into this state? • How do I stop it from doing this? • How do I get it to do what I want? • It usually works - what's changed?

  17. Background Symptoms - Lack of Support • Trainer's View • System takes too much time to train • We don't train for every situation • We don't train on all features • System uses non standard conventions • Hopefully they will learn it on the job

  18. Background Symptoms - Lack of Support • Designer's View • System performed as designed • System design met requirements • System was not designed for that operating condition • System works okay, some don’t understand it

  19. Background Symptoms - Lack of Support • Facility Impact • Workarounds • Work delays & inefficiencies • Unrealized production • Events • Disruptions in production • Safety challenges Difficulties in Production can be precursors to Safety challenges

  20. Background Why Human Performance is of Concern? • Responsibility • People design, direct and supervise operation • Human Impact • Pervasiveness of human involvement • Fallibility • Human behaviour is not fail proof • Experience • Human behaviour is a major contributing factor to • Safety challenges • Production disruption & inefficiency

  21. Background What Could Be Mismatched or Missing? • Support for Desired Performance Person • Education • Job training • Experience • Fitness Desired Performance Operational Environment Physical Design • Workspace • Automation • Feedback • Reliability • Task • Supervision • Procedures • Practices • Culture

  22. Background What Could Be Mismatched or Missing? • Support for Desired Performance • Communication • Authority • Roles Team • Info content • Info structure • Info relations • Culture • Priorities • Resourcing Cognitive Organization Desired Performance Political Physical • Policy • Law • Regulations • Location • Size • Colour

  23. Background A Model of Facility Operation Needs Goals Functions People Systems Agents Working Together Well Tasks •Configuration • Supervision • Intervention • Servicing Automation •Control • Monitoring • Detection • Respond to user Actions

  24. Background How Might Problems Occur? - Design Design for Accessibility • Design without task or user description Goals Functions Step 1 Design (Systems & Automation) Training (People) Working Together Less Well Step 3 Procedures (Tasks) Step 2 Procedure and people compensation

  25. Working Together Less Well Background How Might Problems Occur? - Operations Changes Environmental change Goals Functions Modified goals Systems & Automation Equipment aging Skill loss People New functionality Stress Procedures (Tasks) Additional tasks

  26. Background How Might Problems be Reduced? Goals Design for Use • Design with task and user description Functions Step 1 Step 0 Design (Systems & Automation) Training (People) Task Description Step 3 Procedures Step 2 Control Usage • Limit changes and monitor impacts

  27. Definition & Examples What is Human Factors? • Knowledge • About the capabilities of humans and their interaction with technical systems • Criteria and Methods • For designing systems and workspaces so that user task needs and operational objectives are successfully met. So consistency in performance excellence can be achieved.

  28. Definition & Examples Example - Audible Communication • Understanding Speech - Background Noise Context Normal speech levels (1m) = 55 to 75 dB Design Criteria Speech vs Background Understanding Condition > 5 dB Full None 0 dB Full Concentrated listening < 5 dB Partial Concentrated listening

  29. Definition & Examples Example - Visual Communication AAA • Reading at a Distance Height Spacing Luminance Contrast ratio Factors AAA Design Criteria Distance = 2.5 m Legibility Character Height minutes - arc cm Character - Minimum 5 0.38 Words - Minimum 14 1.06 Words - Preferred 22 1.66

  30. Definition & Examples Exercise - Alarm Display Legibility • Situation • Addition of alarm number to existing alarm display • Design solution • Reduce character spacing to accommodate addition of alarm number • Questions • Impacts on: • Viewing distance - Legibility • User behaviours • Task performance CAR CAR

  31. Definition & Examples Exercise - Alarm Display Legibility • Characterizing Impact • Measure viewing distance • 5x with old display • 5x with new display • Calculate average viewing distance • Repeat for 4 subjects • Determine impact of display change

  32. Definition & Examples Exercise - Display Legibility • Results Discussion • Viewing distance impact • Other influencing factors • Room illumination • Text colour • Subject visual acuity • Subject familiarity with alarm messages

  33. Definition & Examples Example - Display Design • Developing & Maintaining Plant Awareness Current & Past Plant State Expected Plant State • Perception • Comprehension • Projection

  34. Definition & Examples Understanding Monitoring Behaviour • Context • Stable operation • Variability in practice • Questions • Objectives • Strategies • Parameters • Representations • Relationships

  35. Definition & Examples Monitoring Objectives • Periodic examination of current plant state to: • Confirm goals selected • are being achieved • Detect a change from • normal in key • indications

  36. Definition & Examples Operating Goals • Safety and Production • Performance • Health Design Basis Licensed Operating Range * Target Setpoint Current Operating Point Operating Range

  37. Definition & Examples A Monitoring Strategy - Automation Functions Electricity Generation Reactor Power Boiler Pressure Operator Setpoint Heat Transport Pressure/Level Deaerator Pressure/Level Boiler Level

  38. Definition & Examples Types of Information • Control Program Information • Performance • Health Periodic Feedback Indication Continuous Feedback Process Output Process Setpoint Function Adjustment Disturbances Internal Performance Measures

  39. Definition & Examples Information Form • Representations which support: • Value comparisons • Parameter trending with time • Relationships Trend Current Value Bar Chart 101 98.6 95 PLIN LIN N %FP 101 98.4 95 PSA RP SETPOINT %FP 13:44:19 100.0 96.0

  40. Definition & Examples Enhancements to Existing Displays • Trend Display - Reactor Power Range Adjustments 101 98.5 95 Organization PLIN LIN N %FP • Process Outputs +1.0 0.01 -1.0 PERR RP ERROR %FP 101 98.4 95 PSA RP SETPOINT %FP • Process Setpoint 80.0 44.19 20.0 LEVAV AVERAGE ZONE LEVEL %FP • Internal Measure Parameter Substitutions

  41. Definition & Examples Example - New Display Concepts • Heat Sink Monitoring - Outages Expected Decay Heat Actual Heat Produced Heat Removed First Heat Sink Heat Removed Second Heat Sink Fuel Decay Heat Heat Transport Service Water Circulated Cooling • Time Zero • Heat Sink • Heat Sink • Heat Sink • Flow • Flow • Flow • Inventory • Inventory • Inventory * * * * Power (MW) Power (MW) Power (MW) Power (MW) Shutdown Days Reactor Delta T Heat Sink Delta T Heat Sink Delta T

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