(IASA-CE-175564) NASA: ECCKL DBVBLOPHBIT U85- Z 19 E 5 

PCR HUMAN FAC106S UTIREACIIG Final ReFozt, 

15 loo. 1984 - 15 Jul. 1584 (Onioersity of 

Central ElorAda) 116 p HC ACc/H€' A01 IIncla s 

CSCL 05H 63/54 lQ634 

FINAL REPORT 

NASCS: Model Development for Human Factors Interfacinq 

National Aeronautics and Space Administration 

Kennedy Space Center, Florida 

GRANT NCSG10-0010 

15 NOV 83 - 15 Jul 84 

September 15, 1984 

prepared by 

Leighton L. Smith, Ph.D. 

Department of Industrial Engineering 

University of Central Florida 

Orlando, Florida 
ABSTRACT 

The results of an iniensive literature review in the qeneral 

topics of human error analysis, stress and job performance, and 

accident and safety analysis revealed no usable techniques or 

approaches for analyrinq human error in qround or space 

operations tasks. CI Task Review Model is described and proposed 

to be developed in order to reduce the degree of labor 

intensiveness in ground and space operations tasks. An extensive 

number o+ annotated references are provided. 

4 
FOREWORD 

This grant (N4G10-0010) was directed by The Future Projects 

Office at Kennedy Space Center, Florida. 

This report summarizes the results of Phase I. There are 

anticipated to be three successive Phases. Devel oped and 

validated will be two models for addressing the potential for 

human error in ground or space operations tasks. First will be 

The Task Review Model (TRM) which will reduce the degree of labor 

intensiveness in a task.. Second a Human Role Evaluation Model 

(HREM) will determine a Role Criticality Criterion (RCC) for each 

human role in a task which has been reviewed by the TRM. There 

will be different levels of criticality in the RCC. In addition. 

for human roles with undesirable RCC values. the HREM will 

develop a Personnel Management Criterion (PMC) which will 

delineate skill-level and experience required and recommend work 

period, break period, and rest period durations. 
ABSTRACT 

The results of an intensive literature review in the general 

topics of human error analysis. stress and job performance. and 

accident and safety analysis revealed no usable techniques or 

approaches for analyzing human error in ground or space 

operations tasks. A Task Review Model is described and proposed 

to be developed in order to reduce the degree of labor 

intensiveness in ground and space operations tasks. An extensive 

number of annotated ref etences are provided. 
TABLE OF CONTENTS 

r-.T.'f-:!nnp ........................ ii 

AP53 Fix? ........................ iii 

4PF'E;dSI~' A: Cross-Sectional Reference Sheets ...... 17 

W'PEFIC! hC4 Y Et: I?tlrrotanted References ........... L 4- 

Part I: Human Error Rnalysis .*..--. .- 4 

-. 

Pert 11: Stress and Job Performance - . . 60 

Part 111: accidents end Safety . . .) - . 72 

RPPFr:?TX C : Illustrated Example of a Task 

Reviewed by the TRPl . .I I - . . - - - . X 

4F'CFKiDIY D: References ................. 8G 
CHAPTER I 

FINAL REPORT 
FINAL REPORT 

NOSFI: Model Development for Human Factors Interfacing 

Grant NE\G 10-00 1 Q 

Space systems operations comprise a broad spectrum of 

different activities. There are multiple checks of electrical, 

mechanical, and fluid connections; fuel and oxidizer transfers: 

onloading, act i vatingldeacti vat ing pay1 oads/experiments; orbiter 

and space vehicle relocations, etc. II large portion of these 

operations are l-tbor intensive in that many humans, many manual 

tasks, or a combination of both are involved. Many of these 

tasl:.s are also hazardous toward personnel , systems, and missions 

due to the space environment and/or hazardous systems 

involvement. Due to the complexity of space operations. the 

involvement of hazardous systems, and the high degree of labor 

intensiveness, most space operations require long periods of time 

to accomplish. It is noteworthy that the time required for a 

human to successfully accomplish any task increases in direct 

proportion to the complexity of the task. It is anticipated that 

operations activities will be a primary limiting factor in 

determining future flight rates as well as the rate at which 

space experiments and activities can take place and that human 

errors could contribute significantly to a degradation of 

opera t i ona 1 suc c ess . Therefore, methods to evaluate human 

involvement and to analyze the human role are necessary to 

ameliorate the potential for cnntrc’l ing critical errors. 
Let the premise therefore be that there exists a potential 

for human error (hereinafter referred to as HEP: Human Error 

Potential) and that there are a large number of human errors 

which are deemed undesirable in ground and space sysfems' due to 

the character, magnitude, severity, and/or timeliness of the 

consequences of such errors. 

In order to address these two major issues of this premise, 

it is desirable to first quantify the HEP so as to be able to 

predict the likelihood of error commission in a given 

application. The ability to so predict would enable analysts to 

generally characterize the likelihood of severe consequences to 

possible human errors. 

Secondly, it is desirable to delve into the causal factors 

which contribute (or induce) humans to commit errors. Clearly, 

if it is known what makes humans err, then it is presumed 

possible to nodify the situation in some manner or form to reduce 

the HEP. 

Therefore, the approach can be summarized as first being 

able to predict the HEP and second attempting to reduce this 

potential. It is fundamental that being able to predict HEF must 

come before being able to reduce it because if the potential 

cannot be reliably quantified, it would be difficult at best to 

Characterize the efficacy of any HEP reduction efforts. 

Before any attempts are made to address the issuer of the 

premise in this manner, it is advisable to survey the field to 

ascertain what methods and techniques have already been developed 

to deal with HEP. The most logical (and usually the most 

effective) manner in which to survey the practices in uie in the 

3 
field is to conduct a review of the professional literature. In 

this instance the professional literature is construed to entail 

books, journals, dissertations, conference preceedings, pub1 ished 

reports in the private sector, and reports in the public sector 

such as that which is available from the National Technical 

Information Service (NTIS). 

The logic here is that there is no reason to reinvent the 

wheel, namely, if there is a valid, applicable technique reported 

in the field it is more effective use of the time to find it via 

a literature review than it is to develop a new technique from 

scratch. 

It should be intuitively obvious that regarding the topic of 

HEP the ‘field’ is extraordinarily broad in scope simply because 

human beings are involved in nearly all activities. Therefore it 

was decided not to select a field of operation, say manufacturing 

or sports. and investigate what might be reported in literature 

related to that area. This approach would tend to grow in scope 

in direct proportion to the time invested and it could possibly 

overlook usable information available from sources not selected. 

Consequently, an extensive review of the literature was 

conducted in the following manner. The purpose of the review was 

to determine what has been reported in the literature in the 

general areas of (a) human error analysis, (b) stress and Job 

performance and (c) accident and safety analysis. Interest in 

area (a) was predicated on the assumption that effective 

techniques in dealing with the potential for human error have 

bean developed which are applicable to ground (or space) 

4 
operations tasks. Interest in area (b) was predicated on the 

contingency that tangible results of the +irst part of the review 

might not be realized. The rationale was that if no usable 

techniques in human error analysis are evident in the literature. 

then perhaps usable techniques in the area of stress and job 

performance have been developed and reported which could be used 

as a foundation for the development of a human performance 

analysis technique which could be used in dealing with HEP. 

Interest in area (c) was predicated on the idea that usable 

techni ques have been devel oped through anal ysi si of the periods 

following the occurrence of a human error. 

The human error analysis portion of the literature review 

was planned to be as broad in scope a5 possible. Subtopics a5 

classification schemes (taxonomies) , error data banks, causes of 

human error, consequences of human error, and human reliability 

were investigated. 

The stress and job performance portion of the review was 

planned also to be broad in scope. Included were such subtopics 

as job stress, stress due to non-job sources, means of measuring 

(and enhancing) job performance, psychophysical aspects of job 

performance, and fatigue. 

The accident and safety analysis portion of the review 

concentrated on accident investigations and safety program 

development and evaluation. The general results of the 

literature are described in the following paragraphs. More 

specific information can be found in Appendices A and P. 

Appendix A contains a cross-sections' reference sheet for each of 

the first two areas of the literature review. These sheets 

c J 
reflect with respect to area subtopics the type of information 

found and the type of source which provided thfa 1 bj. -:,idtion. 

Appendix B is a list of annotations of sources whit., were 

determined noteworthy. This appendix is broken down into three 

parts corresponding to the three areas of interest. Appendix D 

contain; the references reviewed. This is a complete reference 

listing, meaning that the list ,cites all sources reviewed. Nct 

all of the sources reviewed contained useful information. Those 

sources uhich contained the most useful information are 

speci f i call y discussed in Appendi 5: E. 

The results of the review in the area of human error 

analysis were that in general there were predominantly only 

contributions made by theorists. There were very few reports 

made by empiricists and there were virtually no reports made by 

practitioners in human error ana:.ysis. In fact, the pauclty of 

practitioner provided reports is evidence to the conclusion that 

human error analysis is not an area of prartice at all. In 

addition, it appears that although ther-. may be interest in HEF 

in the field no one is reporting on any direct application 

attempts to do anything about it. 

There were only a handful of reports made by empiricists in 

the area of human error analysis and all of these were laboratory 

studies which addressed the characteristics of different types of 

human error (e.g., muscular coordination, mental computation, 

etc.), and consequently were not applications studies. For 

edification, a::;.dlications studies are investigations which deal 

with a specific activity (or task) in its entirety. Such may be 

4 
done in the laboratory or the fiela. The results of 6uch studies 

are tangible dnd interpretable for applications to other similar 

activities. On the other hand, foundation level studies are 

invariably performed in the laboratory. These studies endeavor 

to establish a general data base in an area of human activity. 

The end result (after many studies) is a compendium of data which 

would provide general design guideline information for a series 

of related tasks. Therefore the results of individual studies of 

this type are not usable for applications, although such studies 

are highly meritorious due to their contributions made to the 

col 1 ect i ve goal . 

As yet these foundation studies have not been performed with 

enough breadth and depth for there to be any useful compendium of 

design guideline information in the area of HEP. 

The reason why there are a low number of instances of 

reported empirical and practitioner studies is most likely due to 

the fact that those individuals interested in human error 

analysis can not identify worthy methods or approaches because 

the large number of theorists in this area are at odds with each 

other. CI thorough reading of the published material from the 

theorists engenders a large tendency towards confusion. There 

appears to be no commonality of purpose and no commonality of 

approach. One grocp avers that HEP is pervasive arid 

uncontroll ab1 e. There have been successf ut techni ques developed 

to predict the error rates of humans, however. The most well 

known technique is The Technique for Human Error Rate Prediction 

- THERP (Swain, 1973). 

In reviewing the sources located in this area a conclusion 

7 
or generalization in spite of the tendency towards confusion does 

surf ace. This qeneralization is that human performance 

activities are not independent. Heme they do not lend 

themselves to traditional methods of analysis such as statistics 

:the techniques of :hich generally call for it5 events to be 

independent). In addition, it appears that most theorists agree 

that human activities are correlated to both the characterixtics 

of the environment and the individual personality. In other 

wordsr it is thought that people do not err predictably in 

similar situations, nor do errors occur predictably person to 

person in the same situation. 

Having ventlared these generalizations, it should be 

recognized that unfortunately insofar as the immediate objective 

previously posed in the premise is concerned, there is no logical 

next ster.!. These generalizations, although perhaps interesting 

and worthy of discussion do not lend themselves to the 

formulation or development of a solution to the stated problem. 

In fact, these generalizations are not sufficient guidance to 

design and conduct an intermediate study the results of which 

would be intended to address the stated problem. Error rate 

prediction techniques as mentioned previously could be utilized 

as evaluators, but short term success can only be expected for 

reasonably simple (non-complex) and/or unsophisticated systems. 

The results of the review of the literature in the areas of 

stress and job performance and accident and safety analysis are 

basically similar to that of the first area of interest. In 

these areas there has been more agreement among the theorists. 

8 
But even though this fact would enable there to be a more uniform 

thrust by empiricists and practitioners such activity has not 

been reported. The bulk of what was reported has been done by 

theurists. Generally, the theorists agree that job performance 

can detrimentally be affected by either an overstress condition 

or an understress condition. In other words, people do their 

best work in job situations whick are neither an overload (too 

many tasks, and/or too little time) nor an underload (not enough 

tasks, and/or too much time). This observation in itself may 

seem profound enough to lend itself to an application. This 

however is unfortunately not the case. The problem is that there 

is no concensus from the theorists (and there have been no 

reports of empirically based results) whiclr quantitatively 

delineates how many tasks are too many or too few or how much 

time is too much or too little. Without this type of 

quaqtitative information job design (or redesign; is not a 

feasible approach to addressing HEF'. 

The general conclusion, then, based on the thorough review 

of the literature which has been conducted is that there have not 

been any techniques or approaches developed to address HEP or to 

conduct a human error analysis. Furthermore, since the sources 

reviewed were predominantly theoretical discourses, there are not 

enough tangitle data to use to build 3' design a set of 

techniques or approaches to deal with HEP or to conduct human 

error analyses. 

It would appear then that the objective of this study as has 

been stated previously in the premise cannot be supported by the 

results of the literature review. This is not the case. The 

9 
fact that nothing has been done before in the empirical or 

practitioner communities (and reported in the literature) is not 

a preventative from doing anything original. The only 

reservation might be that an original approach has a certain 

degree of risk: associated with it in that without documented 

support there is no assurance of success. 

There are two general approaches which can be addressed at 

this juncture on an original approach. The first is to design a 

means of analyzing and quantifying (or predicting) HEP in some 

manner which will have usability with and application to typical 

ground (or space) operations tasks. This wauld be a foundation 

level type study. The second approach is to postpone any formal 

dealings with HEP and endeavor to reduce HEP in an informal or 

indirect manner. In other words. rather than confront HEF in 

ground operations tasks as a reality and try out heuristic 

innovations to deal with it, it might be more effective to 

initially t r y t o deal with the major reasor: why HEP exists in the 

first place, namely the human being. If it were possible to 

reduce the number of human beings involved in a ground (or space) 

operations task, it is logical that the HEP associated with that 

task would go down. Recognize that it is not known how much the 

HEP would 50 down because it is not yet known how to reliably 

quantify HEP. But if this hypothesis that HEF' is directly (or 

positively) correlated to the number of people (or more aptly. 

the degree of labor intensiveness) on a given task, io deemed 

valid, then it is recommended to adopt the second approach as the 

means of initially dealing with HEP at Kennedy Space Center. 
Thus it is recommended that this project involve the 

development and validation of two Human Factors Models: The Task 

Review Model (TRM) and the Human Role Evaluation Model (HREPl). 

The TRM is a means of analyzing a ground (or space) operations 

task. It will isolate the task's key objectives and functions 

and will perform a functional allocation process for each task in 

the interest of reducing the degree of labor intensiveness of the 

task. After space operations tasks have been reduced in labor 

intensiveness using the TM, the MEM will be applied to those 

tasks identified through the use of the TRM as still labor 

intensive. The HREM will consist of two techniques, the Role 

Criticality Criterion (RCC) and the Personnel Management 

Criterion (PMC). The RCC will be a means of evaluating human 

roles to ascertain the severity of the possible consequences due 

to human errors. The RCC will assign a numerical quantity to the 

analyzed tasks and will be designed to be parallel to the 

criticality numerical quantity factors assigned in the standard 

NASA system hardware failure analysis schemes. after the RCC has 

been applied to tasks to determine their criticality, the PMC can 

then be applied to those tasks having an undesirable RCC. The 

F'NC will be a specification of the skill level and experience 

required of humans to accomplish the specific task being analyzed 

and will delineate minimum/maximum (as appropriate) work period, 

break period, and rest period durations. The TRM will be 

developed and validated in Phase I1 and is described in detail as 

follows. Once a Qround or space operations system has been 

reviewed by the TRM and HREM the next logical steps ere one, to 

utilize an error rate prediction technique (e.~., THERP, referred 

11 
to previously) to identify specific human actions which warrant 

further scrutiny, and two to delve into the psychophysical 

aspects of these identified actions. 

12 
Task Review Model 

The purpose of the Task Review Model (TRM) is to objectively 

minimize the degree of labor intensiveness in a ground or space 

opera t i on s task . 44 minimization in the degree of labor 

intensiveness is interpreted to include either a reduction in the 

number of humans involved in the task, a reduction in the 

instances of manual operations in tne task, or both of these 

reductions on an optimization basis within the limitations of 

current automation technology. 

The TRM will be designed to be applied to any type of task 

in a manner which is independent of how the task is currently 

being conducted. This is anticipated to be accomplished by 

compiling information from such individuals as the task designer 

and the task supervisor rather than observing the actual 

execution of the task. 

The anticipated results of a task reviewed by the TRM will 

be two-fold. First, the TRM will provide an objective 

description of what activities must be accomplished in order for 

the reviewed task to be accomplished. The result will be a 

description in the form of a tree diagram or an organizational 

chart. This task description will be streamlined and as 

parsimonious in the number of activities ab possible. Hence such 

a description would form an ideal foundation for a contract bid 

proposal solicitation. Secondly, there will be an assignment 

made for each listed activity. Tho assignment will either be 

‘human’ or ‘non-human. ’ The human aosiqned activities are those 
which will be reviewed by the Human Role Evaluation Model (HREM, 

to be developed in Phases I11 and IV of this project. Similarly 

thio activity assienment facet of the TRM results will provide 

qualified guidance to prospective contractors in how to prepare 

their bids. This requirement shall be realized as a benefit due 

to the fact that each prospective vendor will bid on the same 

conception of the task -- not on each individual interpretation 

of how the task can be executed. 

Generally. the TRM is an analysis approach which endeavors 

to include only those activities which are necessary to satisfy 

the stated Qoal. Let this stated goal be called the Objective of 

the task. The definition which the Objective satisfies is: What 

is the task supposed to do? or Why is the task necessary? 

Therefore the first step of the TRM is to determine the Objective 

of the task. There must be a single simply stated Objective for 

each task. If a selected task cannot be described by a single 

Objective then it will be deemed a higher-order task and, a5 

such- warrant a number of separate appl'cations of the TRM. 

Therefore an additional benefit of the TRM technique is to 

identify all the basic (zero-order) tasks which comprise a 

single ground (or space) operations system (where *system- is 

used to be synonymous with a higher-order task). 

For qualified basic tasks, the next step in the TRM is to 

identify, and label all those activities which are necessary to 

achieve the stated Objective. CIllow for these activities now to 

be called Functions. The determination of those Functions which 

satisfy the stated Objective is the most involved portion of the 

14 
TRY. Not cnly must this portion ensure that there are enough 

Functions specified to fully support the stated Objective, but 

the descriptions of the Functions must be explicit enough for the 

TRM to make the human and non-human assignments to the Function 

in the next step. 

The next step in the TRM determines whether a human can or 

can not accomplish each listed Function of the task. Ordinarily. 

the Functional Allocation step makes this determination on the 

basis of how the human resources can best be utilized. In the 

design of the TRM for this application, the Functional Allocation 

determination will be made on the basis of how available nonhuman resources and technology can best be utilized, because. a5 

stated previously, the primary purpose of this TRM is to 

minimize the degree of labor intensiveness in ground (or space) 

operations tasks. An illustrated example is provided in Appendix 

C. 

Because the primary product of this project is a reduction 

in the potential for human error in ground (or space) operations 

tasks, the Functional Allocation step of the TRM will not provide 

specific descriptions of the character of the non-human 

allocations. Lat it remain for subsequent projects to address 

this issue. As a departure point for prospective projects in this 

vein, the final deliverable of the TRM in Phase IV will include a 

detailed description of the logic applied in the Functional 

Allocation step which accomplishes the determination of whether 

the allocation is to be human or non-human. 

It is noteworthy at this juncture to identify that the 

Functional Allocation step will be desiqned to make a human 

15 
allocation primarily by default. That ir, a human allocation will 

be made only if a non-human allocation cannot be supported by the 

Functional Allocation logic. This is because the primary purpose 

of the TRM is to minimize the degree of labor intensiveness in 

the targeted tasks. 

The e>.act manner in which the TRM will be applied is as yet 

to be determined, but will most likely be of a computer software 

type. It is planned for the TRM to be fully interactive and for 

it to consolidate data gleaned from more than one rourco. 

Further, it is considered highly desirable for the final TRM 

deliverable to operate in real-time and be as easy to operate and 

apply as possible. The attainment of these characteristics will 

be given the highest of priorities in the design. prototype, and 

validation phases of the TRM development. 

16 
APPENDIX A 

CROSS-SECTIONAL REFERENCE SHEETS 

17 
Included in this appendix are three cross-sectional reference 

sheets one each for the literature review areas of human error 

analysis, stress and job performance, and accidents and safety. 

These sheets reflect the general' types of activity considered by 

the references (SUBJECTS) and the general type of source of the 

references (SOURCES). 

18 
APPENDIX A: CROSS-SECTIONAL REFERENCE SHEETS 

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21 
f3NNOTATED REFERENCES 

The annotations are by alphabetical order according to 

author for easy reference and each paragraph gives information 

provided by one author. 

22 
PART It Human Error Analysis 

Adams (1982) 

Feels thaL error is probabilistic and could be simulated using 

Monte Carlo techniques. Human error should be included with 

equipment analysis in determining the reliability of systems. 

Feels, however, this would be impossible. Feels that to be able 

to analyze error fundamental units of behavior whose success or 

failure would be used in the calculations must be established. 

These would be irreducible stimulus-response catagories. States 

that humans are a closed loop system. They can detect and correct 

their own errors. Expresses a common belief that error is 

mu1 t i di mensi onal . tA response can be omitted, performed out of 

sequence, transferred from another sequence, wrongly timed, or 

applied with inappropriate force. Has a current belief that 

human sequences of action are not independent therefore car, not 

be calculated like machines. Bases a lot of his work on Swain. 
Aitken (1982) 

Feels that if faults are slow in developing, the system can alert 

humans to take corrective action, otherwise automatic controls 

are necessary. Factors which affect human response to an error 

conditions are: 1. the process which is being controlled. 2. 

knowledge of the status of the system, 3. prior knowledge of the 

effects of the control action, 4. human factors specifically 

.. 

relating to the operator end 5. training. 

24 
Altman (1964, 1967) 

Tries to find a similarity ammq errors so one can 1. search for 

oiqnificant error 2. identify alternative ways to reduce error 

or its consequences. end 3. evaluate alternative solutions to 

error problems. Feels error classification schemes fall into 

three categories: 1. performance orientation (what a person is, 

or is supposed to be doing when en error occurs), 2. situational 

orientation, and 3. individual orientation (characteristics of 

the person). Associates psychological behavior levels and 

learning categories te.g. , sensing, tracking. and problem 

solving) with error behaviors. attempts to link the basic 

research of psychology with error. Approaches the area of errors 

at a higher level -- managerial or technical. Feels errors 

should be indexed to the kinds and conditions of input and output 

devices or classified by skill and knowledge content. Goes along 

with situational causation of error. Constructs a block that 

relates consequences, revocabi li ty, and detectabi 1 i ty to measure 

error tendency. Feels that in some cases the individual 

characteristics of the worker may be used to classify errors. In 

qeneral each error possible situation has a best way of 

classification: performance, situational, or individual. 

25 
Askren and Regulineki (1969, 1971) 

Feel that repetitive tasks can be modeled. State that hutnab error 

research has fallen into the following categories: oeueloping 

human error classification schemes, determining the siynijicance 

of errors to system operations, establishing human error data 

banks, and devising models and methods for describirg and 

including human error data in system reliability analyses. 

Define the following equation to describe reliability: 

where e(t) = error rate 

This equation is supported with a very simplistic derivatim and 

the knowledge that error distributions generally fit well with 

Weibull, gamma and log-normal distributions. Feel that this 

applies to continuous operation tasks such as vigilance. 

monitoring, and tracking. 

26 
Beek, Haynam and Markisohn (1967) 

The authors were tasked by the Navy to research tile Navy’s human 

reliability statistics and sugqert improvements. Thus, this 

study is specific to the Navy in operation and ma-n-enance 

procedures. The procedure that will be describe+ here was 

reviewed by Meister. The systems of error reporting used by the 

Navy were reviewed and critiqued. The authors describe in 

detail the intricacies of the two models mentioned below. This 

study did a small literature search. Most previous studies have 

substantiated the fact that a significant percentage of system 

unreliability is caused by human error. Feel it is impossible to 

get reliable data and it is virtually impossible to test people 

in a laboratory and use the result5 Jar predicting human 

performance under actual conditions. Even if this were possible 

the results would not apply to another person. CIgree with 

setting up a data base a5 the forefront of the research effort on 

human error. Feel the need to be able to predict human error 

without depending on humm performance data since it is 

unreliable. Human error predictions should be inferred from 

existing equipment performance data. Define human error as any 

action of the human element of a system that is inconsistent with 

a predetermined behavioral pattern established in the system 

specifications and in the resulting system design. System 

failure is subgrouped a= total system failure and system 

degradation failure. Two approaches to quantative techniques 

were developed: 1. Elementary Reliability Unit Parameter 

Techni que (ERUPT). This technique groups components of the 

27 
system into elementary reliability units (ERUs), the lowest 

levels at which maintenance is performed. This uses existing 

equipment CI reliability data to predict human reliability. i. 

Multivariate correlation techniques. These are used to relate 

personnel characteristics to failures. The problem with error 

reports is that people are reluctant to file them either becauss 

of the risk of self-incrimination or co-worker incrimination 

since many reports are used for disciplinary or promotion review 

purposes. Also, some systems give categories to choose from in 

filling out the report. If too many categories are given only a 

few actually get used. Refer to Shapero (1960) who said 20 to 

54% of all system malfunctions in nine missile systems studied 

were caused by human error. People arbitrarily blame most 

problems on lack.: of training or failure of personnel to follow 

procedures. Feel a taxonomy is needed before anything else in 

human reliability research,. Feel that human reliability lacks 

common definitions. Feel that the only errors to be included in 

reliability analysis are those that affect system performance. 

Examples of classifications: terminal error, design error, 

operating error, maintenance error, contributory error, 

performance of a required action incorrectly, failure to perform 

the required action, performance of a required action out of 

sequence, performance of a non-required action, errors of 

omission (1. errors of memory and 2. errors of attention), and 

errors of commission (1. errors of identification, 2. errors ot 

interpretation, and 3. errors of operation) . This report divides 

error into two categories: 1. Predictable - established between 

28 
the inconsistent behavior and some external influence. This type 

of terror can be reduced by human factors design. 2. Rmdom 

errors -- usually when this is identified as the cause there is 

no further investigation. "A11 system failures and malfunctions 

(except certain laboratory tests) can eventually be traced back 

to some form of human error, whether it occurred on the drawing 

board, in fabrication, in testing, in operation. or in 

maintenance. " To improve error reporting an impartial party 

should be used to evaluate the failure. The second method of 

multivariate correlation mentioned earlier correlates average pay 

grade, average time since educational training, average time to 

evaluation, and average formal education to human error. 

29 
Carnino and Griffon (1982) 

Give the following catagories of human error 1. operating errors. 

2. maintenance errors, 3. testing errors, and, 4. design 

errors. Support the situational cause of human error theory. 

Characteristics of the work station which have caused human error 

may be grouped into eight classes: 1. work organization, 2. 

design of the work station, 3. time and duration of work. 4. 

personnel education and training, 5. physical environment. 6. 

social environment, 7. history of the plant, and 8. individual 

performances. Give listings of these classifications in detail 

-- same idea as Ferformance Shaping Factors (PSF). [See Embrey 

and Swain3 Most frequent causes of human failures are procedures. 

work orqanization. and lack of efficient controls. The role of 

procedures is expanded on since procedures are the interface 

between man and machine. 
Childs (1980) 

Discusses parametric tests of significance (on normally 

distributed scores 1 especially relative to error-time 

experiments. States Bradley’s optimal-pessimal paradox and then 

refutes it. This work preceeds Askren (1982) and contradicts it. 

Bradley’s optimal-pessimal paradox is stated as follows: If 

performance conditions are optimal, then parametric statistical 

tests tend to be pessimal and vice versa. These are the 

assumptions: 1 . error probabi 1 i ties are equal across a1 1 task 

segments and fit a Poisson distribution, 2. error commissions 

uniformly increase task execution times, 3. component error 

times are orthogonal. 4. robustness of parametric tests is 

greatly reduced by skewness, and 5. if errors are present there 

is greater variability in score distributions and hence tend to 

normalize the distribution. Refutes these assumptions because 1. 

people simply do not work this way, 2. errors depend on the 

response stimulus required, and 3. skewness does not matter as 

long as the distribution i5 homogeneous in form and variance for 

var i ous treatments. 
Cross (1982) 

Looks at the quantitative evaluation area. Uses fr-equanceconsequence diagrams to demonstrate total risk. Event trees show 

a cause-and-then-effect relationship where fault trees show a 

effect-and-then-cause relationship. Suggests constructing both 

to analyze a situation. The event tree can be time oriented and 

a1 1 OWL for dependencies between systems. The fault tree analyzes 

the failure of each system independently. These techniques are 

mainly used to gain a greater understanding of the system under 

consi derat i on. 

7- 3 L
Embrey (1976, 1981, 1984) 

Looks at Performance Shaping Factors (PSF) and expert judgement 

to analyze systems and evaluate the probability of failure. Uses 

the computerized Success Liklihood Index Method (SLIM) in 

conjunction with a Multi-Attribute Utility Decomposition (MAUD) 

routine to help reduce bias. In "Application of Human 

Reliability Assessment (HRA) Techniques to Nuclear Energy Process 

P1 ant Design" approaches HRA from a cost effect i veness 

standpoint. Analyzes effect of design chanlges on human error. 

Says that the growing application of computers for routine 

control functions pushes people to higher control levels which 

require decision making, diagnosis, trouble shooting, and 

planr,ing. Different anal yt i cal techni qL;es are needed for 

proceduralized actions and situations where decision making 

functions predominate. Possible anal ysi s of Pr_gsgd_gyal iney! 

si&uation_s A. task analysis approach which includes 1. task 

step 2. inputs, 3. outputs, 4. feedback, 5. error potential. 

6. system implications, 7. error recovery, and 8. design 

implications; b. event trees approach is warranted if task 

elements are discrete and form an ordered sequential sequence 

that moves forward in time. Possible analysis of Complgy 

SLtuatiens (where thinking is required) 4. operator action 

event tree (OAET) model which define operator actions associated 

with critical states of a sequence. B. critical decioion/action 

(CDA) operator centered model -- defined in terms of consequences 

of the decision/action. If a CDA fails it will have a 

signi,ficant effect on safety, and/or production. The CDA model 
involves less routine decisions than those analyzed by the OAET 

model. Has developed a system for analyzing a situation with the 

CDAs. It is necessary to identify each CDA associated with 

changes of state. This is based on Rasmussen’s model of the 

interaction of skill-, rule- and knowledge-based behavior. From 

analysis of error reports characteristic types of error can be 

associated with each CDA. For each CDA a diagram can be drawn 

for additional information. Discusses limitatians of Technique 

for Human Error Prediction (THERP) - no sensitivity analvsis 

available and applies only to proceduralized tasks. Has 

developed a technique to overcome this. C. SLIM - task is 

evaluated as a whole. I+ is quantified via the structured 

application of explicit numerical judgements 9rom groups of 

ex pert s . (Success Likelihood Inde:: Methodology). This is 

applied by computers using MAUD. Discusses algorithm using PSFs 

and expert judgements and SLIs. Since weights are used for each 

PSF a designer can see where improvements might have the most 

benefit, thsrefore the cost effectiveness criteria is satisfied. 

D. Influence diagram is discussed. 

34 
Feggetter (1982) 

Usee a checklist based on a syst- -.s ap[,roach for urrderstandinq 

human error and includes such headings as stress, fatigue. 

arousal, and personality. Feels we usually find the source of an 

error but don't really know why it occurred. Feels that it is 

not possible to categorize errors into unique classes and says 

that there seldom seems to be a single cause for error. Says 

there is a combination of cognitive, social, and situational 

+actors which give rise to erroneous actions. These are 

elaborated on as f0110WS. Coqni t i vg Sygt_pm: acqui sit i on , 

manipulation, use of information, allocation of attentional 

resources (overload), emotions, thought processes, past history, 

and experience. sgcial: role perception and pressures from other 

people. SituatiphE: physical environment and stress. Thinl:.~ 

research should be shifted away from memory structures and over 

to memory processes. Produces a checklist based upon currant 

knowledge of human behavior and the mechanisms and system 

characteristics which predispose the human operator to e- ror. 
Hunns (1982) 

Feels that to analytically predict the full set of signiticant 

event chains associated with a given human/hardware system is not 

yet within our capabilities. Human error (or failure) carries 

connotations of blame and personal deficiency. This is the reason 

given for somc of the inadequacy in error reports procedures. 

Since people take blame, they tend to not report errors as they 

should. The majority of human errors are corrected by the person 

concerned and r.ever become ekident to a thiro party. This goes 

along with the feedback principle mentioned in other literature. 

Feels turrent data approaches are ineffectibe. "So not only is 

the human factors data collection activity frustrated by t'le 

unyielding naturs of the observa',ioIi environment, but at an even 

earlier stage the process is cmfounded becadss no fundamental 

basis exists to define the type of information khich is really 

required." This supports those who believe that a taxonomv is 

needed before hun.an error research can progreEs. Goes into an 

eiaborate discussion on how a data bdse sho*-lld be built dith 

backing from classical probability theo;y. 
Lewis (1981) 

Attempts to give a general purpose theory on error. Recognizes 

that most theoretical approaches are specialized and involve 

language. math, and the acquisition of perceptus motor skills. 

Cln error becomes an error by virtue of its failure to conform 

with some appropriately chosen standard of correctness. "Under 

conditions of felt urgency, we make mistakes. And, since error 

is inherently proliferous. yet more mistakes come piling in on 

top." Says that errors are self-limiting and people naturally 

want to rid themselves of them. Desired goals cannot be attained 

if error gets in the way. Management should not have to convince 

people to recognize their own erroneous thinking. Feels that of 

the current literature Swain and Guttman (1980) offer the best 

classification scheme: omission and commission with the 

subcategories of commission - extraneous acts, sequential errors. 

and time errors. Gives definitions of error change according to 

the situation and what is perceived to be a correct action. 

Error can occur because a situation was appraised incorrectly, or 

because inappropriate action was taken. Feels there are two 

types of error: 1. failure to make a distinction that needs to 

be made and 2. making of a distinction that does not need to be 

made (omission - commission dichotomy). Rewords these as 1. 

errors due to significant omissions and 2. errors due to 

misdirective inclusions. This was because of the trouble caused 

by the word "need" above. Says that human error is compounding. 

37 
Meister (1964, 1964, 1971, 1973, 1982) 

Feels that simulation based methods are more powerful than nonsimulation methods and that no general purpose methodology is yet 

available. Feels strongly there is a great need to develop data 

banks. Feels that much work needs to be done to solve the 

problem 09 task dependency relationships (this refers to those 

who say that classical probability theory does not apply to human 

error since there are dependent relationships involved. 1 Feels 

that most of the quantitative methods available +Aday are special 

purpose or require a particular form of input and are still in 

the developmental stages. Says that the frequency of Human 

Initiated Failures (HIF), that is failures that result in 

degradation of performance of the system and reduce equipment, 

range from 20-80% of all failures reported. States that the 

distribution of individual operator errors tends to approximate a 

Gaussian distribution with the mean a5 constant error and the 

standard deviation as variable error. Says that operator errors 

compound linearly. Gives tables of error rates. Thinks we should 

concentrate on work situation to reduce errors, and that most 

errors are situation caused. Says a lot about what should be 

done and has a lot of criticism to hand out. Feels that human 

error includes causes of error built into the system, i.e. poor 

human factors design. Classifies error as to cause, effect, and 

stage of occurrence. Gives two categories of operator error, 

i di oiyncret i c (apt i tude and mot i vati on 1 and si tuati onal 

(procedures and training). Types of error are system induced, 

38 
design induced, an3 operator induced. Feels that the casual 

classifications of error do not imply understanding the error 

source or the mechanism of the error process. Makes the 

statement that errors made with discrete tasks are more quickly 

corrected than those made with continuous tasks. Feels that 

automation significantly increases the requirements of functional 

allocation, maintenance, and logistics. Feels that the causes of 

production error are: lack of training, lack of motivation, 

inadequate work space, poor layout, poor environmental 

conditions, inadequate human factors design, inadequate methods 

of mat?rial handling, inadequate procedures, and poor 

supervision. Says error causation is usually due to multiple 

factors. Says that errors are caused by a mismatch between the 

capabilities of the operator (idiosyncratic factors) and the 

demands of the job (situational factors). There is an error 

potential in man which is not realized until a predisposing 

condition, creating a mismatch, permits the error to occur. The 

predisposing condition is a catalytic agent which translates a 

potential into an actual error. Feels that nothing is inevitable 

about error. Errors occur when demands and capabilities do not 

match. To reduce error mismatching must be reduced. This 

contradicts a prevailing theory that to err is human and hence 

errors cannot be avoided. Feels that human variability is not the 

main cause for system degradation since errors do not build up. 

Humans are adaptable, and thus are desirable for many tasks. But 

this adaptability also makes humans one of the causes of error. 

Says in 1982 that random errors, i.e., those produced by the 

39 
inherent variability of people. can be reduced by training and 

proper selection of personnel. Classifies types of errors as 1. 

fail to perform required action, 2. performance of unnecessary 

action, 3. performance of required action at an incorrect time, 

and 4. making a substandard response. Says 40X of equipment 

failures are the result of error, and as much as 82% of 

prodcction defects are caused by human error. Def i nes 

idiosyncratic factors to include personal relationships, 

emotional conflicts, and attitudes. Gives a list of PSFs that 

predispose a human to error. Feel., to evaluate a job a human 

factors expert should ask questions about each PSF along with: is 

task within worker's capability, does task cause fatigue or 

discomfort, is feedback provided, is too much precision required 

or too many movements, and is the phvsical environment adequate. 

40 
Petersen (1980) 

Researches the fields of education, management, psychology and 

human factors engineering. Looks at basic research as well as 

applications. Intends for work to be used as a test book. Says 

an old view is that the prime causative factor in occupational 

injuries is human error rather than physical conditions. In 1939 

Heinrich gave four basic motives for unsafe acts: improper 

attitude, lack of knowledge or skill, physical unsuitability, and 

improper environment. Says this view is seen as oversimplified, 

but this is what most industries use. Heinrich said managers 

control accident prevention. Says the behavior of people needs 

to be understood and controlled in order to prevent accidents. 

Supports the multiple causation theory of human error. Discusses 

a particular type of fault tree which is management based. Human 

error results from one or more of three things 1. overload 

(defined as a mismatch between a person's capacity and the load 

placed on him in a state), 2. a decision to err, and 3. traps 

that are left for the worker in the workplace (i.e., poor human 

factors design). Under the first category falls overload in the 

forms of physical, physiological, and psychological. Capacity is 

due to a combination of physical, physiological and psychological 

endowments, current physical condition, current state of mind, 

current level of knowledge, skill, temporary reduced capacity due 

to drugs, alcohol, pressure, and/or fatigue. Load is due to a 

combination of the quantity of information processing. 

environment, worry, stress, current state due to personal life, 

41 
and/or hazards faced continuously. State is due to the level of 

motivation, attitude, arousal, and/or biorythmic state. The 

second category deals with peer pressure, pressure for productlon 

quotas, accident proneness, and the instance of risk taking 

because it is inappropriately considered unlikely for a mishap to 

occur at the time of the taken risk. The third category deals 

with incompatability between the human and the workplace. Human 

factors applications are generally used to correct this. Quotes 

Chapanis that humans commit errors because it is logical that 

they do so in the situation they are in. Says human errors are 

caused; they do not just happen. Situations cause error and the 

greatest gain in controlling human error can be made by altering 

the situation. Says that improvements from redesign of equipment 

are greater than that from selection of or training of personnel. 

It is easier to change equipment than people. Design 

characteristics which increase the probability of error 

commission include violations of operator expectations, mismatch 

of abilities and demands. induced fatigue causing circumstances. 

inadequate facilities or information, and difficult, unpleasant. 

or dangerous tasks. Says risk taking occurs because judgement of 

risk is not directly related to the hazard as measured by the 

worker-s performance skills. Skilled workers take less risk than 

unskilled; younger persons take more risks of a more severe 

nature than older persons; females take less risks than males. A 

risk taker is a person with a high anxiety level, high 

sociability, and low emotional stability. No strong relation 

between vision acuity and accident repeaters was found. High or 

low arousal levels cause errors. Thinks an optimal arousal 

42 
state for peak ef-ficiency is needed. In discussing accident 

proneness, says that accident frequency is unrelated to 

intelligence when such is adequbte for the situation. 

Individua?s whore level of muscular reaction is above their 

levels of perception, are prone to more frequent and more severe 

accidents than those individuals whose level of muscular reaction 

is below their perceptual levels. Errors occur when man is used 

where a machine would be better. Poor adjustment causes 

accidents such as when a person starts a new job and ha5 a hard 

time adapting. When people are down, they cause more accidents. 

To stop people from causing accidents 1. direct confrontation by 

management, 2. training or coaching from management, and/or 3. 

behavior cadification techniques may be used. Group norms are 

perhaps the single most important determinant of worker behavior. 

To avoid the decision to err 1. positively reinforce safe 

behavior, 2. buiid strong work groups, 3. build attitudes 

conducive to safety, and 4. have management that is employee 

centered. Quotes Schulzinger (1956) that the tendency to have 

accidents is a phenomenon that passes with age. It decreases 

steadily after reaching a peak at age 21. Men are significantly 

more liable to accidents than women. Irresponsible and 

maladjusted individuals are significantly more liable to have 

accidents than normally adjusted individuals. Accident prone 

people make up a very small part of accident statistics, less 

than that attributable to chance as determined by a Poisson 

distribution. Goes into detail on how to specifically accomplish 

ways to avoid errors. Each topic is delved into in detail in 

43 
separate chapters of the text. Most is involved with management 

theory. 

44 
Pickrel and McDonald (1964) 

Feel that the extent and cost efforts to eliminate sources of 

human error should be commensurate with: 1. frequency with which 

the error is expected, 2. freouency with which a failure will 

occur as a result of the error, and 3. probable consequence of 

the failure condition. Task criticality ratings are determined 

from these points. Give a probability worksheet and criticality 

analysis, and feel that even though the method has shortcomings 

it is better than nothin9. Feel that another method would be to 

come up with error probabilities. 

45 
Rasmussen (1982); Rasmussen, Pederson, Mancini, Carnino, Griffon, 

and Gagnolet (1981); and Rassmusren and Rouse (1981) 

Say it is not good enough to study the effects of error, internal 

causes need to be looked at. Feel systems should be designed to 

tolerate error since human error can not be predicted reliably. 

This is consistent with Meister in the criticality of using 

quantitative methods for predicting error. This also implies 

the belief that to err is inevitable, which is stated later as 

human errors are the inevitable side of human adaptability. Say 

that Centralization increases size and complexity of a system. 

Feel that recommendations for bet>er training with stricter 

administrative controls is not the answer, better design is. 

Tt>tsj correlates to others that feel the situation causes more 

errors than the human alone. Caused errors are unfulfilled 

purposes. People find the easy way out. It is thought a 

solution to the cause for error has been found when something 

familiar is uncovered. Easy way to fix humans is t o t e l l them to 

try harder but this is not a satisfactory solution. People 

generally don't commit errors because they want to. Most error 

reports are not reporting all the errors people commit. They 

incicate only the errors which are not corrected because they 

have an effect that is either irreversible or not immediately 

apparent to the person. Therefore, reports are biased by the 

potential for feedback. Say that 80-90X of the cases of errors 

fall into three catagories: ommission of steps, mistakes among 

alternatives (upldown, +I-), and operational "improvement" 

46 
(people making up a "better way" a5 they go along). People 

typically know what to do and when, but not always how. 

Omissions and inadequate consideration of latent causes or 

inappropriate side effects in selecting procedural steps are the 

two main causes of error. Suggests feedback be used whenever 

possible since people correct their actions when it is provided. 

Suggest that control panels cause errors since people have to 

relate dial readings to the state of the system. Such calls for 

interpretation and integration. A lot of this work centers around 

nuclear power plants. Support the multiple causation theory. "In 

a system of balanced design major accidents will depend on a 

complex chain of events including equipment faults and latent 

risi::y conditions, together with human mistakes and errors." 

Gives a definition of accident as: "an unwanted transfer of 

energy because of lack of barriers and/or controls producing 

injury to persons, property, or process. 'I Quote from Johnson: 

"Typically the effect of exotic and unprealctable human acts is 

masked by the frequency of trivial equipment faults." When 

humans are put into a system the risk taken is not that they will 

cause accidents, but rather that they may not succeed in 

preventing them. The problem in the present context is that 

people in the system must be considered as system components and 

that human error data are needed. Say that risk analysis (as 

compared with reliability analysis) involves the estimation of 

the probability of several categories of accidental event 

sequences related to the relevant 

damage to people and environment 

categories of risk such as 

a5 well as to loss of major 

47 
equipment. This means that the overall probability related to a 

specific =onsequence must be calculated by a probability model 

derived from the family of relevant accidental event sequences 

tcgether with data on the component failure modes involved. 

Collecting data for error rate information on humans is difficult 

due to feedback. Reliability of human performance in response to 

infrequen,L demands ranges from .2 to .6. Therefore error rates 

from general error reports will not apply to this situation. An 

accident is typically causLd by a sneak path for events, created 

by the accidental timing of a considerable number of normal and 

erroneous human acts together with latent risky conditions and 

equipment failures. Define the external mode of malfunction as 

the immediate and observable effect of human malfunction upon 

task performance, as opposed to internal mode of malfunction 

which comes from within the person. Expand on the types of 

behavior -,id the errors classified under each: Automated skillbased behavior (types of error: task not performed, erroneous 

acts, and extraneous effects on other and nearby systems), Goaloriented and rule-based behavior (types of error: deficiencies 

in coordinating segments of skill-based behavior, errors in 

recall of reference data, and mistakes among alternatives). 

Technique for Human Error Rate Prediction (THERP) is used here. 

Knowledge based, goal controlled behavior (latent effects of 

decisions come into play). This type of behavior can not be 

predicted. Regarding PSFs: "In general, it is advantageous to 

distinguish clearly between causes, which are chanQes or events 

followed by a change of events, and more general factors which 

influence the flow of events by modifying human behavior or 
probabilities of response. ” 

49 
Sh,.ridan (1981) 

Gives a little better definition of event trees and +ault trees: 

event trees characterize with what probabilities different major 

events follow other everiLs. Fault trezs characterize hr w Boolean 

"and" and "or" logic determines the various ways that major 

system failures might occur, the "top events" of which &ra 

transferred to event trees. Says we can't treat human error like 

.lachine error because people rail differently ttan machines do 

and objectivity is more difficttlt. States theory that error 

occurs when a person's internal model is out of calibration with 

the real world or when the environment causes a pel-son to commit 

an error. Feels in general the world of human error research is 

in great disarray -- no good definition of error (changes from 

place to place) no pinpointed CIUSQ (different theories), 

different classification schsmes, human errors compound each 

other, people correct their own errc 6 (these last two affect 

grobability calculations), errors in one stage of development of 

a project compound r8it.h others later on. Agrees with biased 

error reports statements. Suggests rating errtrs with 

- relationship to their effect 1. safety consequences, L. 

economic consequences, and 3, personal consequences. Deals with 

humans as monitors of automated systems and the hurran's 

detection of an errcr condition in the mechanical system. 
Siege1 ( 1970) 

Develops eight models with various characteristics. One even 

incorporates both equipment and human performance so as to yield 

e prediction of integrated system reliability. Feels there has 

been little effort towards human reliability in a system context 

and considering human reliability with equipment reliability to 

get system reliability. Acknowledges that behavioral studies are 

considerabiz in number but they are restricted in application. 

Believes that current system operator/maintainer unreliability 

situations contribute to total sysL2m unreliability more than 

hardware unreliability situations do. Therefore, considering 

only equipment reliability during design phases exposes a 

designer to the risk of a gross overstatement of system 

reliability. The models are stochastic since human behavior is 

dynamic and can not be represented by deterministic models. 

Human behavior is time varying. People learn, read differently 

under stress, vary in ability and attitudes. Leadwship and 

personal factors affect human performances humans get sick and 

fatigued. Decision making ability affects system perfor nance. No 

two humans are alike. They are vary flexible and adaptive. The 

models are stochastic digital simulations and sequentially 

simulate the acts and behaviors of the operatore/maintainers in a 

man machine system as the tasks involved in mission performance 

are executed. "Current perLormancc is based on such variables as 

past performance, the actions of other crew members, the current 

stress level, the input of individual proficiencies, and random 

fluctuations. All models consider the impact of initially 

51 
unanticipated events such as malfunctions and emergencies on 

operator /system performance. Some even emphasize social 

interactive and group iaciiitative variables as well as 

individual performance variablcs. " 
SinQleton (1972) 

Feels that recent attempts to classify errors emphasizes the 

distinction between causes, effects, and remedies. Considers 

analytical techniques. Goes along with those who feel a taxonomy 

is needed before anything else. After practical experience with 

national reporting to the data base. a taxonomy would emerge. 

Points towards this philosophy in the techniques for improving 

production books. Says classifications have fallen under seven 

types: commission : omission; reversible : irreversible; systematic : random: detectable : undetectable; formal : substantive: 

recoverable by machine, man, or neither: inputs : outputs : 

decisions. Reviews each of these techniques from other sources 

and concludes that the existence of all these different 

techniques conf irms the complexity of the problem. Discusses 

analytical techniques versus statistical techniques. Accidents 

are rare and the reporting of results is distorted. As for 

distribution curve fitting: "Poisson can usually be interpreted 

as resulting from a situation of equal risk, a negative binomial 

results from a situation where there are some higher risk 

elements all the time." Type A errors result from sitclations 

where all the elements are at a higher risk level for part of the 

time. The critical indicant method researches near-accidents and 

thus provides a larger sample size. Observation methods have a 

trained person investigate the accident immediately after it 

happens. The mort obvious technique for dealing with human error 

is to automate. The practical situation turns out that machines 

are poor at error correction while people are exceptionally good 

53 
in this area. In addition, pr3per human factors design 

techniques contribute to total error reduction. Allocation of 

function, interface and workspace design, selection and traininq, 

overqualified personnel, rigid procedures, contingency planning. 

human and hardware based monitoring, working hour controls. and 

other conditions all are contributory to error reduction. 

Reiterates problems in error - investigation because of two 

theories: 1. to err is human and 2. humans are responsible for 

their own actions including errors. Placing the blame is 

involved and people will not own up to their mistakes in general. 

Recognizes that humans will make errors and classifies the kinds 

of errors which are likely to occur. Identifies their causes and 

effects and devises methods of minimizing error rates and the 

consequences of errors. 

54 
Swain (1964, 1947, 1970, 1973) 

Was the develo, - of THERF (Technique for Human Error Rate 

Prediction) a quantitative technique for predicting human 

reliability. Constructs a fault tree to show relationships 

between tasks performed by a human being. Uses the AIR Data 

Store (Payne and Altman 1964) along with expert judgement a5 to 

individual probabilities of success and applies probability 

theory to arrive at a final reliability figure. The AIR Data 

Store was the first attempt at a human error data base. Also had 

contributed to the development of SHERB (Sandia Human Error Rate 

Bank). believes a data bank, should come before all other 

research. Set up forms to be used and a filing system for all 

the information gathered. These techniques are used for 

procedural ired cases. Feels that modeling ebf orts have been 

adequate and researchers should concentrate in other areas. Says 

human errors occur when people 1. 3 fail to perform a task, L. 

perform a task incorrectly, 3. put in wrong task, 4. perform 

task out of sequence, or 5. fail to perform task in allocated 

time. Feels that efforts should now be concentrated on a data 

bank. Analysts should not consider the consequences of error in 

a data bank, only the probability of error. Should develop a 

bank first. After analysis of the bank, a taxonomy should be 

developed. Computerization is not universally recommended. Is 

the originator of the Performance Shaping Factor (PSF). Suggests 

making a list of FSFs and rate each one for each human error 

reliability analysis. This io basically a quantified subjective 

judgement of the PSF. Feels that forms for reportinq errors and 

55 
those put in the data bank should be unstructured. Should be 

able to repeat the error by the description, like describing an 

experiment. Should record preceding tasks and following tasks. 

Suggests that substitution of machines for human functions often 

decreases rather than increases system re1 iabi 1 i ty. Says the 

techniques for error quantification as of 1964 are trees, 

scaling, experimentation, and literature search. Lists the 

factors of error: conditions of learning, performance caoacity. 

attention or alerting conditions, information given by 

instructions, feedback conditions. environmental vari ab1 e=. and 

effect of personal equipment and clothing. Feels that taxonomy 

and modeling techniques are needed. Says there is always a 

tradeoff between costs and error reduction. Says that most errors 

are caused by the design of the work situation rather than by 

imcompetence, poor motivation or carelessness. Situations cause 

most of the errors. The situation in which a worker performs is 

controlled by management and can affect motivation and Job 

satisfaction. Errors are when an action exceeds tolerable 

limits. Errors are inevitable unless 1. there we no tolerable 

limits set, 2. tolerance limits exceed the r.cnge of human 

variability, or 3. opportunities to commit errors are small. 

Says that error is a natural and inevitable function of human 

variability. People err because they can do so many different 

things in so many different ways. Feels that there is no such 

thing as error proneness. Recommends taking tho work situation 

approach, that is matching a job's demands and people's 

abilities. Feels that preventative measures are .nore effective 

56 
than remedial ones. Provides a definiticn of error: conflicts 

between extra- and intra-individual factors cause errors. Types 

of error are 1. fails to perform task, 2. performs task 

incorrectly, 3. introduces extraneous task elements, 4. performs 

task out of sequence, or 5. fails to perform task in allotted 

time. Hence behavior reduces the success of system. Gives a 

comprehensive listing of the FSFs. Discusses research done on 

rest periods by the Enqlish. 

57 
VanCott and Kinkade (1971) 

Discuss variable and constant errors. Provide the definitions 

which are commonly accepted by the discipline. This is a 

landmark foundational compendium of design guideline information 

for equipment design. Attempts to apply classical probability 

theory to human errors and to calculate the probability of 

occurrance of human error. Agree with Askren in that 

measurements of human character i st i cs f 01 1 ow a Gauss1 an 

distribution including errors which follow a bell-shaped curve. 

Allow the mean to be characterized by constant error and the 

standard deviation to be Characterized by variable error. In the 

case of variable error, they feel that human errors compound 

linearly with go-no-go situations. 

58 
Wheale and O’Shea (1982) 

Study the effect of noise on error rate. The hypothesis was that 

noise affects performance by increasing arousal. Extroverts 

scored more errors than introverts and high neuroticism scale 

people also had more errors. The results showed that intense 

noise does not have any harmful effect. In fact it masks 

distracting stimuli. Level of arousal was also not related to 

noise. It tended to stabilize and to suit task demands. 

Theorize that noise should have affected a short-term memory 

tasl.. Intermitent noise has the greatest effect on increasing 

the error rate. Noise increases arousal only when the tasi. is 

challenging and the noise represents a potential threat to the 

satisfactory completion of the task,. Extroverts have sociability 

and impulsiveness. Impulsiveness is related to destractability 

which increases errors. Their final result: noise does not 

affect the level of arousal but the level of arousal does affect 

the error rate of humans. 

59 
PAKT ii: Stress and Job Performance 

A1 1 ui si ( 1978) 

References Chiles (1967) and his four problems of performance 

assessment: 1. criterion, 2. task taxonomy, 3. reliab-Iity 

of performance measuresz and 4. role of face validlty. 

Comments that by 1978 only problem 1. is still pertinent. 

Further, reports that the U.S. Supreme Court has endorsed that 

performance-based criteria be required for acceptance validation 

of selection techniques. and that a test validated on one task 

cannot be used for another task. unless in can be shown there are 

no significant differences between the two tasls. 
Cox (1978) 

Provided are three approaches to studying stress: 1. the 

dependent variable is a person's response to a disturbing 

environment, 2. the independent variable is the stimulus 

characteristics of a disturbing environment, and 3. investigate 

the difference between the stimulus and the response as an 

indication of "lack of fit." Also provided is a response-based 

model of stress which relates a stressor-to-stress relationship 

to a stimulus-to-response relationship with respect to 

physiological and psychological forms of stress. Indicates that 

it has been empirically shown that conditions thought to cause 

stress do not always cause performance degradation. Identifies 

three difficulties with stimulus based definitions of stress: 1. 

it can not be reliably identified what aspects of real-life are 

actual 1 y stressf ML . 2. stress present in an individual can not 

be quantified, and 3. human variability across conditions has 

not been adequately investigated. Finally, the investigator is 

cautioned to self-examitre the experimental design because it is 

usually not clear whether the stress exists in the eye of the 

subjects or in the eye of the empiricist. 
Cox ar?d MacKay (1981) 

Provided is the transactional model of stress: stress is 

correlated to a particular relationship between humans and their 

environment. There are five stages in a typical stress 

experience cycle: 1. the relationship of the person to the 

qources of a demand, 2. the person's perception of the demand 

and hislher ability to cope. 3. the person's psychophysical 

reaction to the imbalance between the actual demand and the 

person's actual ability to cope, 4. the impact of the person'i 

coping responsesr and 5. the level and character of feedbacl in 

the loop. Generally extremes of sensory stimulation (auditory 

noise, heat (or lack. of heat) , humidity, isolation. congestion. 

etc. 1 and extremes of workload are considered to be stressful. 

7 

62 
Uses Meister’s (1977) human perf ormonce model. States that the 

term stress is used indiscriminately in reliability literature. 

Stress is often discussed in connection with the effectiveness of 

a human operator in coping with various types of system 

emergencies. Others use stress only in explaining the effects 

induced when inadequate time is available to accomplish a serics 

of tasks. Besides extreme conditions, one is also interested in 

the implication of stress +or day- to-day reliability. States 

that a human functions best under conditions when there is a 

moderate load. The performance would be less thap maximal either 

if the demand is to\) high or if the demand is too low. Suggests 

that Hebb’s (1955) arousal theory implies that a certain amount 

of variety is necessary for minimizing the effects of load 

stress. Deficles stress based on McGrath (1970) as the result of 

an imbalance between demand and the organism’s capacity to meet 

that demand. States that this is, in turn, a function of the 

intrinsic capability of the operator, his training, and his 

physical state &hen confronted with a demand. Refers to the 

Eysenck. Personality Inventory and its indication of extroversion 

and introversion personality traits. It is recommended that 

extremes of these traits should be avoided when placing humans in 

a monitoring task (calling for extroversion). Says effective 

training can considerably reduce stress praduced by emergency 

situations. Presents the following measures that should be 

considered to cnsure re1 i ab1 e operator performance in stresof ul 

condi,tions: 1. incorporation of hutan factors principles, 2. 
selection of operators based on their ability to cope with 

stress, 3. emphasis on training in stressful situations. 4. 

provision of a task. sperifica+ion with a reasonable level of 

built-in activity in order to provide tbe operator with an 

optimal level of activation, and 5. consideration 0.f using 

mediation techniques to increase the individual '5 resistance to 

stress. 

64 
Finley (1969, 1970) 

Addresses the taxonomies developed by Alluisi. Miller and Meister 

for task analysis. Al~o discusses the Fleishman-Parker approach 

wbich is based on the method of differential psychology and 

ability identification. Took the reports of operational tasl. 

analysis and used Meister's taxonomy to develop a set of 75 

behavioral dimensions. These were divided into six classes: 1. 

individual gross body movement abilities, conceptual and 

thinking abilities, 5. psycho-motor abilities, 4. perceptualcogni ti .re abi 1 it i es. J. memory functions, and 6. adjustment 

potential. 

-I 

c 

65 
Hogan and Hogan (1982) 

State that the Stress Activation Syndrome (SASI entails all 

processes connoted by the term 'stress.' There are three 

components: 1. stressors, 2. stress responses. and 3, 

subjective or psychological factors that mediate between 1 and 2. 

Stressors a:-e defined as physgcal (stimuli that palpably and 

noxiously impinge on an individual 1 and psychological (stimuli 

that generate the anticipation of harn, -- either physical or 

social . There are five general categories of stress responses: 

1. General Adaption Syndrome (3AS) which is a psychological 

phenomenon describing the relationship between alarm coping and 

exhaust i on. 2. fight vs. flight where physiological changes in 

- the GAS serve to energize the system to one or the other, -. . 

beroming ill which is a completely involuntary complex function 

of several co-occurring conditions. 4. psychosomatic disorders 

whicp lie between the realms of psychology and medicine. and 5. 

long term performance decrement due to a combination of illness. 

distractability, inattention, fatigue. and stress related abuse. 

Present five theories to stress: 1. emotional homeostasls -- 

the stressful state is characterized by emotional arousal 

(usually anxiety), somatic changes, and certain kinds of 

cognitive activity in response to stressors, 2. person to 

environment fit -- good match leads to high performance. 

expressed satisfaction, and low stress whereby a poor match leads 

to performance decrement. di ssat i sf act i on, anx i et yr depressi or). 

elevated blood pressure and heart rate, and somatic complaints, 

66 
3. sociological -- advocating that the causes of stress are 

found in the structural features of the social environment not in 

the individual, 4. Type A Behavior -- which is the behavior 

pattern characterized by excessive aggressive drive, impatience. 

a sense of time urgency. a compulsive need for achiev-nt, and a 

need for e::treme job involvement, and 5. Life Changes -- based 

on Social Readjustment Ruling Scales (SRRS) which are currently 

being investigated on how they relate to illness onset. Discuss 

four problems with stress research: 1. personality measures are 

not powerfully associated with the magnitude of stress responses. 

2. there is a conceptual confusion due to a lack of common terms 

and descriptors. hence making it difficult to correlate 

independent studies, 3. the fact that psychoanalysis is solving 

problems but not in the manner of it being research from which 

conclusions. results, etc. can be derived and used for the 

general good. and 4. there still exists an undeveloped 

measurement base for stress. States a socioanalytic theory of 

stress which conceptualizes the subjective factors which mediate 

stress responses by characterizing the human as a group-living 

and culture-using animal who needs a character structure (rules. 

values. and expectations) and a role structure (individual 

perception of rules, valu@s, and expectations) . State that 

stress proneness (or vulnerability) is a direct function of self 

esteem which is an indirect and complicated function of the 

character and role structures. Recommend to first establish an 

adequate measurement base then study the relationship among 

perrmality structure, stress vulnerability, and vocational 

placement. 

67 
Howarth (1978) 

Provides four theoretical views of stress: 1. biological 

(human lifestyle differs too much from current level of 

adapt i on 1 , 2. developmental (human is unprepared for the 

social (exposure to ? demands of chosen lifestyle). 3. 

conflicting social pressures compels human tc play inconsistent 

roles, and 4. phenomenological (there is a discrepancy between 

the human's lifestyle and his/her aspirations). 

Presents the quality of emplovment survey and provides a factor 

structure which analyzes the importance of the job 

characteristics derived from the si. 'y. A job is divided into 

eight basic aspects: 1. tasl. content, 2. autonomy and 

control, 3. supervision and resources, 4. relations with cowxkers, 5. wages and rewards, 6. promotions, 7. wor)..ing 

conditions, and 8. organizational context. Argues that most 

people want to work (bovond the need for economic gain) and that 

deprivation of work is a stressful and potentially damaging 

situation. 
Latarus (1976) 

Provided an interactional definition of stress: stress occurs 

when there is a demand which taxes or exceeds one’s adjustive 

resources. States that frustration is a form of harm already 

evident in a human. Threat is anticipation of harm. Harm is 

physical, psychological , or social damage. Defined demand a5 a 

request or requirement of physical or mental action and implies 

some time restraint. Four comprehensive observations are made: 

1. stress develops from a particular relationship between the 

person and his/her environment. ? the social background of 

stress experience is a critical factor, 3. a major problem with 

laboratory studies is that the 5UbJeCts usually are instructed 

(or they expect) that the stress e::perience is controlled and 

will be of short durations. and 4. there is too much ambiguity 

in a vast catalog of terms used in the stress area, hence mal.inq 

subjective response data subject to scrutiny. Coping with 

demands is both psychological (cognitive and behavioral 

strategies) and pilysiological. If normal coping is ineffective, 

stress is prolonged and abnormal responses may o~tiir. Prolonged 

stress may result in functional and/or structural damage. 

McGrath (1976) 

States that stress occurs when d human confronts a i-.mand which 

is perceived to be beyond his/her capabilities, given that the 

human wishes to cope with the demand. Makes the controversial 
statement that situations of small disparity between the demand 

and one's perception of capability to cope are more stressful 

than the opposite. 

Peter son ( 1980 ) 

Refers to stress as load and breaL:s it into long-term and shortterm categories. Short-term is defined as the present work-. 

situation. Short-term load is a function of current and outride 

influences and internal feelings. Factors involved are the tasi 

in itself, the psychological load e.q., task ambiguity. tasl. 

success criteria. feedbacb. tasl.. confus:on, shifting goals and 

taskss environmental load. fatigue, and boredom. Long-term is 

defined as relating to the effect of stressors associated with 

life situations or current mental health. Long-term load is the 

relationship between a person's life situation and his 1iLelihood 

of being involved in accidents. 
Provided eight sources of stress: 1. accelerated information 

pr ocessi ng L. noxious environmental stimuli 3. perceived 

threat. 4. disrupted physiological function due to a disorder, 

5. isolation and confinement, 6. blockinq. 7. group 

pressure, and 8. frustration. Source 8 was redefined by 

Frankenhauzer (1975) as a lack. of control over events. 

c) 

Welford (1973) 

Stated that stress arises whenever there is a departure from 

optimum conditions of demand which the person is inhibited from 

rectifying. Agrees with Hebb (1955) that a plot of performance 

versus demand is a conve:: parabolic curve which indicates low 

performance for both low and high demand. 

71 
PART 111: Accidents and Safety 

CSnderson, R. (1983) 

Discusses the data collected in slipping. falling, and tripping 

accidents. It induces traininj and experience, number of hours 

worked, form of payment. 

Corbett (1978) 

Emphasizes the need of an accident causation model based on 

psychological processes for adequate analysis of accidents. Thc 

logic of the psychological aspects of accident occurrences is 

presented as memory interpretaticn and identification. This 

logic results in sensory inputs which produce failwe and 

incorrect output. 

Craven (1981) 

Emphasizes the importance of using a formal strategy in fire and 

explosion investigations so thst evidence is not disturbed and 

opinionating is sirpressed. Suggests a checklist of common 

cacegorieo of behavior Ctaxonovyl which may be associatkd with 

intentional fires. 

72 
Danaher (1980) 

States that controller errors are not due to the mechanical 

systems but are due to human mistakes in attention, judgement. 

and communications among personnel and supervisors. 

Fowler (1980) 

Desires for the human error analysis problem readdressed with air 

traffic controllers. The idea is not to reduce error potential 

but to increase the number of aircraft under positive control by 

a single controller. The operators (controllers and pilots) must 

be understood and appreciated in terms of their capabilities and 

1 imitations. 

Asks for a different approach in accident data collection. 

Questions whether industry accident reports are ever read. 

States that current approach is to try to devise a means of 

identifying hazards so as to determine which warrant revision. 

Calls for a data bank which includes near-misses, and a need to 

train operators to better recognize human errors as they occur. 

73 
Levine (1976) 

States that industrial accidents have been reduced significantly 

by considering the hazardous properties of machines. lighting. 

noise, and physiological limitations of operations. behavioral 

scientists have introduced social and psychological attributes 

(including life situations) of workers as additional dimensions 

of accident etiology. 

Patnoe (1978) 

States that it is generally agreed in the field of accidmt 

investigation that 80% of all accidents are the result of human 

failure and the other 20% are attributable to mechanical failure 

or acts of God. States that Holmes and Rake (1967) conducted a 

landmark study on social stressors and the Social Readjustment 

Rating Scale (SRRS). States that test data from Holmes and 

Masuda (1974) establishes a consideration between life events of 

the individual and accident causation. 

74 
Piniat (1978) 

There is a need 

unsafe acts. Ex 

to place greater 

mines principle 

emphasis on the control of 

of motivati n theory as a 

potential tool for the safety professional to minimize the 

frequency and severity of harmful events by control 1 ing unsafe 

acts. Stresses job satisfaction factors. The safety 

professional must be able to utilize the most valuable resource 

at his disposal, the employee, to optimize the efficacy of his 

efforts towards a safe and healthful en*dironment. 

Slovic (1982) 

Refers to Wilder's theory of risk. homeostasis which is a 

hypothesis that people have a target level of risk. in different 

activities and these are not necessarily the same target for all 

activities. This will cause safety measures to be ineffective 

from time to time. Feels that reducing people's tolerance for 

risk should have a salutory r=ffoct on safety. 
Smillie and Ayoub (1976) 

Present a simulation modeling approach for aiding in the 

discovery of potential hazards that are essential for the 

functioning of the accident process. This model is a closed-loop 

system which considers the major factors of presented, expected, 

and perceived information, the actions of the situation, and the 

feedback to the human. Incorporate new features into model of 

Hale and Hale (1976) and include the flow of information 

constructed according to a multilinear events sequencing approach 

suggested by brenner (1975). 

Swain (1972) 

States that occupational accidents are frequently written off as 

results of humar! error or poor workmanship. Provides four 

models: 1. single, 2. sequential, 3. logic diagram, am+ 4. 

dynamic models. Suggests that ergonomists should concentrate on 

making improvements in the working environment instead of ma1::ing 

unfruitful attempts to reduce natural variations of human 

behavior. 

76 
Wei ner ( 198O) 

Sees airline collisions 6s results of system induced errors9 

resulting from A system that emphasizes airspace allocation and 

political compromise rather than dealing directly with the 

various problems facing controllers and pilots. 

77 
UFFENDXX C 

ILI-USTRATED EXAMPLE OF A TASk REVIEWED BY THE TRM 

78 
APPENDIX C: Ill-ustrated Exaqle of a Task Reviewed by the TRM 

0 

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APPENDIX I) 

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