Human Error:Human Error: Perennial and Pervasive

A Presentation at the

Human Factors and Ergonomics Society

8th San Diego Chapter Symposium

March 8, 2003

George Edw. Seymour, Ph.D. Space & Naval Warfare Center, San Diego

March 8, 2003 2March 8, 2003

Quotes:Quotes: “Anyone can make mistakes, but only an idiot persists in

his error.” Cicero, 44 B.C.

“Sometimes we may learn more from a man's errors, than from his virtues.” Henry Wadsworth Longfellow

“Every great mistake has a halfway moment, a split second when it can be recalled and perhaps remedied.” Pearl S. Buck

“I have learned as a composer chiefly through my mistakes and pursuits of false assumptions not by my exposure to fonts of wisdom and knowledge.” Igor Stravinsky

The “third leading cause of death in the United States are fatal mistakes that occur as a result of the misuse of the extraordinary medical technologies that we now have available. These accidents are responsible for over 400,000 deaths yearly---more than tobacco, stroke, diet, alcohol, drugs, firearms, or automobiles…” David Lawrence, 1999

March 8, 2003 3March 8, 2003

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

March 8, 2003 4March 8, 2003

Objectives:Objectives:My Objectives Today are to:

1. Spotlight & Focus on Error in Human Factors,

2. Focus on “Critical” HF Error Topics, i.e., Inverse Power Law,

3. Survey Recent HF Error Topics, and

4. Provide a Useful HF-related Resource Document.

March 8, 2003 5March 8, 2003

Not Covered TodayNot Covered Today During August 17-21, 1995 at the University

of Oregon, a group of assembled scholars discussed the topic of “human error” that included: Abram's BoxAnimal - MagnetismChernobylClever HansCrystal PowerDiscovery of the Planet VulcanGraphology

Keely's Motor ManiaMartian CanalsN-RaysParanormal Metal BendingPhrenologyPiltdown ManPolywaterPsychic SurgeryPyramid Power

Soal's ExperimentsThe Cat-Rat RanchThe Indian Rope TrickThe Invasion From MarsThe Seattle Pitted- Windshield EpidemicThe Secret Life of PlantsThe Spanish PrisonerTulip Mania, etc.

March 8, 2003 6March 8, 2003

““Honest Mistake” or “Big Mistake”Honest Mistake” or “Big Mistake”“Two months after a double bypass heart operation that was supposed to save his life, comedian and former Saturday Night Live cast member Dana Carvey got some disheartening news: the cardiac surgeon had bypassed the wrong artery. It took another emergency operation to clear the blockage that was threatening to kill the 45-year-old funnyman and father of two young kids.”

“Responding to a $7.5 million lawsuit Carvey brought against him, the surgeon said he'd made an honest mistake because Carvey's artery was unusually situated in his heart. But Carvey didn't see it that way:

"It's like removing the wrong kidney. It's that big a mistake," the entertainer told People magazine..”

March 8, 2003 7March 8, 2003

What is an Accident, an Error?What is an Accident, an Error? “There is no consensus in the literature what

constitutes an ‘accident’. Unplannedness and undesirability are more or less universal features of both dictionary definitions and the few references pausing to elucidate a definition” (Woodcock, 1989).

By definition, “accidental deaths are usually unforeseen, violent, and unexpected” (Webster 1986).

By definition, error is: “Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim; the accumulation of errors results in accidents” (Kohn et al 2000).

March 8, 2003 8March 8, 2003

Extreme Ho: Locus of EffortExtreme Ho: Locus of Effort

} or {

User Focus:

p(E) = f(P + T + O)

P = personnel selection,

T = training, procedures, and

O = organizational policies

Environment Focus:

p(E) = f(D + H + C)

D = defective design,

H = human computer interface, and

C = task complexity

Manufacturers & Media vs. FDA & Six-Sigma

March 8, 2003 9March 8, 2003

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

March 8, 2003 10March 8, 2003

““Error” in the Published LiteratureError” in the Published Literature

Human Factors Publications: (key word) Source & Search Range / Data Range / Number Human Factors: 1958 - 2001 1964 - 2000 20 Ergonomics in Design 1993 - 2001 1994 - 1997 3 Annual Proceedings 1972 - 2001 1972 - 2001 111

March 8, 2003 11March 8, 2003

The Problem: In The WorldThe Problem: In The World “On the evening of October 2nd, 1996, an AeroPeru Boeing

757, flight 603, with 61 passengers and 9 crewmembers, took off from Lima, Peru... All nine crew members and 61 passengers lost their lives ” Vigilant & Williamson (2002).

“July 25, 2000, a small piece of debris on the runway at a Paris airport caused a tire to blow out on an Air France Concorde during its take off. A heavy slab of rubber that spun off from a tire created a shock wave in a wing tank, which burst open and sent fuel streaming into an engine intake. As flames trailed two hundred feet behind, the aircraft rolled out of control. The crash killed all 109 people on board and 4 more on the ground.” Chiles (2001).

March 8, 2003 12March 8, 2003

The Problem: In The NationThe Problem: In The Nation Accidents are the fifth leading cause of death in the U.S.

( > 95.500 in 2000) (Vigilant & Williamson, 2002)

In 1995 “2,900 children died in motor vehicle crashes, 950 children drowned, more than 1,000 died from fire and burns,” plus 200 accidental gun deaths (NCPA, 1997).

In 2001: Number of unintentional deaths: 98,000. “The highest death total was 116,385 in 1969 and the lowest recent death total was 86,777 in 1992 (lowest since 1924). Unintentional injury deaths were up 2% in 2001 compared to 2000 A fatal injury occurs every 5 minutes and a disabling injury occurs every 1.5 seconds. Wage losses, medical expenses, property damage, employer costs, fire losses and other expenses related to unintentional injuries and fatalities cost Americans an estimated $516.9 billion in 2001. That's equal to about 52 cents of every dollar spent on food in the United States.” (National Safety Council, 2001).

March 8, 2003 14March 8, 2003

Most Dangerous Jobs: U.S.Most Dangerous Jobs: U.S.What is the Correct Rank Order?

Construction Fishing Logging Mining and drilling Piloting small aircraft Roofing Steel working Truck driving

March 8, 2003 15March 8, 2003

Most Dangerous Jobs: U.S.Most Dangerous Jobs: U.S.

This is the Correct Rank Order: Logging (122.1 deaths per 100,000 workers) Fishing Piloting small aircraft Steel working Mining and drilling Roofing Construction Truck driving

The death rate for “astronauts and cosmonauts over the past 40+ years is (as of 02/03) about 7.5%, or 7,500 per 100,000 -- something like sixty times the rate for loggers.”

March 8, 2003 16March 8, 2003

The Problem: In The NavyThe Problem: In The NavyDeathsDeaths

Traffic

624

Recreation

141Aviation

155

Shore/Ground/OpMV

134

Afloat

19

Total Deaths: 1,076

Total Deaths: 1,076

“In the last five years (FY97-02), mishaps cost the Navy $4 BILLION and 1,076 LIVES!”

“175 Sailors and Marines died in FY01”

(Turcotte, 2002)

March 8, 2003 17March 8, 2003

Human Error, USN/USMC FY97-02Human Error, USN/USMC FY97-02

No. of Class-A MishapsNo. of Class-A Mishaps Human ErrorHuman ErrorNon-HE

19%

Navy/Marine Aviation* 138 of 170

Navy Afloat 41 of 50

Navy Operational Shore 36 of 48

Navy PMV 295 of 350

Non-HE

18%

Non-HE

25%

Non-HE

16%

*FY97-01F/FR/AGM

HE 81%

HE 82%

HE 75%

HE 84%

FY02: 27 March

March 8, 2003 18March 8, 2003

Example 1: Hay ScaffoldExample 1: Hay Scaffold

Someone “stacked bales of hay to make a very unstable scaffold. This “hay stack” was so wobbly that it had to be propped up with boards to keep it from falling.”

This and subsequent examples from the Naval Safety Center (2003)

March 8, 2003 19March 8, 2003

Example 2: Popped CornExample 2: Popped Corn

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

March 8, 2003 20March 8, 2003

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

March 8, 2003 21March 8, 2003

Example 4: Pool LadderExample 4: Pool Ladder

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

March 8, 2003 22March 8, 2003

Example 5: CandlesExample 5: Candles“The liquefied whatever it is gets real hot in those holders. They have been known to flare up, spill and splatter. Even worse, some gel candle holders have been reported to shatter and spew hot gel all over.”

We all know about candles, right? Wrong! “That's exactly what happened to this young lady. A burning gel candle "exploded" and hot gel covered her hand. This photo was taken three weeks after the incident. She has no feeling and may require surgery to get her hand working properly again.”

March 8, 2003 23March 8, 2003

Recent Estimates of Human ErrorRecent Estimates of Human Error APA Journal Abstracts: 8% - 18% (Harris, et al, 2002) DNA: 1 in 267 (Kay, 2000) Engineering: .003 (during construction) Eyewitness: 34% - 60% (Saliba, 2000; Visual Expert, 2001) Fingerprints: 20% - 50% (Berry, 2002; Harris, 2001) Human Factors Research: .05 Medical: 1 in 25 - 1 in 200 (Kogan, 2000; Maddox, 1997;

Woods, 2003) Power Stations: 20% (CRIEPI) Software: 10% - 15% (Mann, 2002) Voting systems: 1.6% - 6%

March 8, 2003 24March 8, 2003

Practical (and Scientific) ViewsPractical (and Scientific) Views Source of Failures (is not less careful people). Safety is “built-in” (but change & goal pressures). Organizational success is not about avoided risks

or reduced errors; rather it’s “creating safety by anticipating and planning for unexpected events and future surprises.”

Individual success is not about Hindsight Bias (blocks learning process); rather “begins with each of us being willing to question our beliefs to learn surprising things about how we can contribute to the potential for failure in a changing and limited resource world.” (Woods, 2003)

March 8, 2003 25March 8, 2003

Sound Familiar? Consider: Sound Familiar? Consider: Creative adjustment to current “problem”

(hay stack) Ignoring advice, directions, or rules (gas,

popcorn, pool ladder) False knowledge transference (candle) Misjudgments during dual processing (cell

phone or distractions while driving) Admitting errors is an organizational

function (Edmondson, 2002) Causal inference errors (Hannigan & Reinitz,

2001)

March 8, 2003 27March 8, 2003

Hyperlinked Resources: IHyperlinked Resources: I American Iatrogenic Association (2003). Medical Error: 1988-2000. Berry, S. (2002). Pointing a Finger at Prints. LA Times Casey, S. (1998).

Set Phasers on Stun and Other True Tales of Design, Technology, and Human Error. Aegean.

Central Research Institute of Electric Power Industry (CRIEPI). What is Human Factors Education.

Chiles, J.R. (2001). Inviting Disaster. Harper Collins. Covello, V. and P. Sandman. (2001).

Risk communication: Evolution and Revolution. in Wolbarst A. (ed.) Solutions to an Environment in Peril. Baltimore, MD: John Hopkins University Press (164-178)

Edmondson, A. (2002), Learning Curve: How to Turn Mistakes Into Knowledge. Harvard Business School Reports.

Engelke, C. & Olivier, D. (2002). Putting Human Factors Engineering into Practice. Medical Device & Diagnostic Industry.

Grabowski, M. & Roberts, K. (1998). Risk Mitigation in Virtual Organizations. Journal of Computer Mediated Communication.

Grout, J. (2002 ). Glossary of Error-Proofing Terms. Gudzyk, K. (2001). Umbrella Against Mistakes. The Day.

March 8, 2003 28March 8, 2003

Hyperlinked Resources: IIHyperlinked Resources: II Hannigan, A.L. & Reinitz, M.T. (2001).

A Demonstration and Comparison of Two Types of Inference-Based Memory Errors. Journal of Experimental Psychology.

Harris, D. (2001). Smudged Prints: Experts Question the Authority of Fingerprint Analysis. ABC News.

Harris A, Standard S, Brunning J, Casey S, Goldberg J, Oliver L,Ito K, Marshall J. (2002). The Accuracy of Abstracts in Psychology Journals. Journal of Psychology, March  v. 136  no. 2  p. 141-8

Johnson, C. (2002). Accident Analysis & Safety Links . Kay, L.I. (2000). DNA Statistics Found Insufficient … Forensic

Evidence. Kogan, M. (2000). Human factors viewed as key to reducing medical

errors. APA Monitor. Kohn, T., Corrigan, J. & Donaldson, M. (Eds.) (2000).

To Err is Human. National Academies Press. Maddox, M. (1997).

Designing Medical Devices to Minimize Human Error . Medical Device & Diagnostic.

Mann, C. (2002). Why software is so bad ... Technology & Science

March 8, 2003 29March 8, 2003

Hyperlinked Resources: IIIHyperlinked Resources: III National Center for Policy Analysis (NCPA) (1997). "Childproofing"

America. National Safety Council (2001). Report on Injuries in America, 2001. Naval Safety Center (2003): Hay scaffold Popped Corn Truck

Pool Ladder Candles Papanek, V. (1973). Design for the Real World. Bantam. Saliba, C. (2000). Eye of the Beholder. RCN. Turcotte, S. (2002). Joint Service Safety Conference. April 4. Ultimate Crash Site: Crash Video Archive. Vigilant, L. & Williamson, J. (2002).

To Die by Mistake: Accidental Deaths. Visual Expert (2001). Errors in Eyewitness Identification Procedures. Woodcock, K. (1989).

Accidents and Injuries and Ergonomics: A review of theory and practice. Proceedings of the Annual Conference of the Human Factors Association of Canada, 1–10.

Woods, D. (2003). Behind Human Error: Human Factors Research to Improve Patient Safety. APA (Monitor)

March 8, 2003 30March 8, 2003

Recent Books of InterestRecent Books of Interest

Logic of Failure 1996

Human Error 1990

Inviting Disaster 2001

Normal Accidents

1999

The Limits of Safety

1995

Managing the Risks of Organizational Accidents

1997

Set Phasers on Stun

1998