Table Judged Reasons for Failure in Events Cited 22 XIV

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Название	Table Judged Reasons for Failure in Events Cited 22 XIV
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5.5Olympic Swim Meet Scoring Device that Could Not Be Altered (lack of flexibility in design and systems management)

At the Barcelona Olympics in 1992, the Brazilian swim meet judge Da Silvieri Lobo meant to give champion Canadian diver Sylie Frechette a 9.7 score. Inadvertently, she hit the wrong button on her handheld computer terminal and the score came up 8.7. She tried to make a change by re-entering the score but the system software would not allow the change. Confusion and delay followed, coupled by the difficulty of the Japanese assistant referee in understanding the judge’s Portuguese-accented English. The audience demanded a score, and the referees finally decided that the 8.7 would stand (Casey, 2006).

5.6Counting of Instruments and Sponges in Complex Surgeries (lack of appreciation for workload/distraction effects)

Two surgeons and two human factors professionals (one of whom was the writer) observed 10 complex (up to 10-hour) surgeries in a major Boston hospital. On multiple occasions it was evident that unrealistic expectations were being placed on operating room (OR) scrub and circulating nurses to perform accurate instrument and sponge counts to ensure that what went into the patient also came out. (“Foreign bodies” left inside patients after they have been sewn up cause infection and incur large malpractice damage claims for doctors and hospitals.) In addition to counting, the nurses must do many tasks to assist the surgeons and anesthesiologists. In this operation, simultaneous counting and performing of other duties resulted in counting errors that caused significant delays and the need to x-ray patients when the procedures were almost completed.

The observation study also revealed the lack of sufficient information in handoffs between doctors, between nurses (who may leave because of a shift change in the middle of a procedure), and between doctors and nurses. The counting and handoff problems are now recognized as areas that need to be addressed. Automatic optical scanning of bar-coded sponges and computer-pattern recognition are being developed to make the counting process more reliable and less demanding on the nurses. It remains to be seen whether it will work (Author, personal experience).

5.7VCR Remote Control (technology overkill)

VCR remote-control devices, or “clickers,” come in many varieties, mostly different from one another, and most seem to have buttons the user never learns to use. The VCR clicker is often cited as an example of technology overkill. Its complexity leads many users to abandon efforts to master it. Fortunately, errors in its use are not life-threatening. For additional information, Degani (2004) has a whole chapter on VCR controls.

6.0LESSONS LEARNED FROM HUMAN AUTOMATION FAILURES

What are the lessons learned from the 38 human-automation interaction failures in the preceding chapters? Table 1 lists specific reasons for the 38 failure events along with their relevance (in this author’s judgment) to four main causal categories: (1) design of hardware and software, (2) procedure, (3) management, and (4) training.

Note that all categories are well populated. This is not surprising. The four causal factors are interdependent. Interface design and procedures go together. Management is responsible for creating a culture of safety and ensuring that the design is working and the procedures are being followed. Operators will not understand the design and the procedures without proper training. No amount of training can make up for poor design and procedures. If hardware and software are not well designed to make operation efficient and natural, especially when off-normal and rare events occur, then operator error can be expected. Good procedures can enhance efficiency and safety, but with sufficiently off-normal events there may be no established procedures. The operator must figure things out and decide what to do, and management is responsible for selecting operating personnel capable of coping with unexpected events.

Table 1. Judged Reasons for Failure in Events Cited

FAILURES CITED	DESIGN	PROCEDURE	MANAGEMENT	TRAINING
AIRCRAFT
Flaw in mode indication	X
Over-reliance on autopilot after fatiguing flight		X		X
Icing disengaged autopilot, manual recovery failed	X			X
Automation state change not communicated to pilot	X		X
State transition not communicated to pilot	X
Pilot misunderstanding of how automation worked				X
Pilot impatience, lack or training or judgment				X
Confusion over FMS waypoint codes		X		X
Control mode errors, misunderstanding the automation	X			X
Taped pitot tubes: poor maintenance & inspection by pilot		X	X	X
Pilot failed to follow TCAS advisory		X	X	X
Software bug caused roller-coaster ride	X
Software bug caused failure of systems and displays	X
Software bug case blackout of displays	X
Shortcutting of required maintenance procedures		X	X
Cutting corners in manufacture; poor human interface	X		X
Ignorance of reset operation	X			X
Ill-defined procedures and traffic management		X	X
Poor design led to pilot control reversal	X			X
Control tower automation may reduce runway vigilance			X
OTHER VEHICLES
Over-reliance on automation; lack of failure awareness			X	X
Poor management planning	X		X
Designer gadget fantasy gone wild	X		X
Poor assumptions and lack of coordination in design	X		X
Poor assumptions in anticipating software requirement	X		X
Failure to communicate to operators a procedure change			X	X
PROCESS CONTROL
Multiple failures in design, maintenance and management	X		X
Design, maintenance, procedures, management, training	X	X	X	X
Poor anticipation of unsafe interactions during design	X
Operators shortcut of recommended safety procedures		X	X
Poor communications regarding authority			X	X
OTHER SYSTEMS
Poor interface design; lack of usability testing	X		X
Lack of anticipation of critical safety requirements		X	X	X
Rush to manufacture precluded precautionary care	X	X	X
Nurses complaints about programming disregarded	X		X
Lack of flexibility in systems management	X		X
Lack of appreciation for workload/distraction effects		X	X	X
Technology overkill	X		X