Table Judged Reasons for Failure in Events Cited 22 XIV




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6.8Mystification and Naive Trust



Human supervisors of computer-based systems sometimes become mystified and awed by the power of the computer, even seeing it as a kind of magical authority figure. This leads quite naturally to naive and misplaced trust. This was particularly well articulated by Norbert Wiener (1964), who used as a metaphor a classic in horror literature, W. W. Jacobs’ The Monkey’s Paw. The metaphor is salient.

In this story, an English working family sits down to dinner. After dinner the son leaves to work at a factory, and the old parents listen to the tales of their guest, a sergeant major in the Indian army. He tells of Indian magic and shows them a dried monkey’s paw, which, he says, is a talisman that has been endowed by an Indian holy man with the virtue of giving three wishes to each of three successive owners. This, he says, was to prove the folly of defying fate.

He claims he does not know the first two wishes of the first owner, but only that the last was for death. He was the second owner, but his experiences were too terrible to relate. He is about to cast the paw on the coal fire when his host retrieves it, and despite all the sergeant major can do, wishes for £200.

Shortly thereafter there is a knock at the door. A very solemn gentleman is there from the company that has employed his son and, as gently as he can, breaks the news that the son has been killed in an accident at the factory. Without recognizing any responsibility in the matter, the company offers its sympathy and £200 as solatium.

The theme here is the danger of trusting the magic of the computer when its operation is singularly literal. If you ask for £200 and do not express the condition that you do not wish it at the cost of the life of your son, you will receive £200 whether your son lives or dies.


To a naive user the computer can be simultaneously so wonderful and intimidating as to seem faultless. If the computer produces other than what its user expects, that can be attributed to its superior wisdom. Such discrepancies are usually harmless, but if they are allowed to continue they can, in some complex and highly interconnected systems, endanger lives. As new computer and control technology is introduced, it is crucial that it is accepted by users for what it is—a tool meant to serve and be controlled ultimately by human beings (Sheridan, 1992). The story of the monkey’s paw, highlighted by Wiener, the “father of cybernetics” in his last (Pulitzer Prize-winning) book, is a lesson about the hubris of technology that is relevant to planning NGATS.

6.9Remedies for Human Error



Given some understanding of the error situation, the usual wisdom for keeping so-called bad errors in check, according to the human factors profession, is (in order of efficacy) (Sheridan, 2002):


  1. Design to prevent error. Provide immediate and clear feedback from an inner loop early in the consequence chain. Provide special computer aids and integrative displays showing which parts of the system are in what state of health. Pay attention to cultural stereotypes of the target population. For instance, since the expectation in Europe is that flipping a wall switch down turns a light on, when designing for Europeans, do not use the American stereotype of flipping the wall switch up to turn the light on. Use redundancy in the information, and sometimes have two or more actors in parallel (although this does not always work). Design the system to forgive and to be "fail safe" or at least "fail soft" (i.e., with minor cost).

  2. Train operators. Train operators about the mental models appropriate for their tasks, and make sure their mental models are not incorrect. Train operators to admit to and think about error possibilities and error-causative factors; even though people tend to catch errors of action, they tend not to catch errors of cognition. Train operators to cope with emergencies they have not seen before, using simulators where available. Use skill maintenance for critical behaviors that need to be exercised.

  3. Restrict exposure to opportunities for error. To avoid inadvertent actuation, ensure the fire alarms or the airplane exit doors have two or more activation steps and use key locks for certain critical controls that are seldom required. However, be aware that this limits the operator's opportunity for access in crisis.

  4. Alarm or warn. Too many alarms or warnings on the control panels or in printed instructions tend to overload or distract the observers so they become conditioned to ignore them. Tort lawyers would have everyone believe that warnings are the most essential means to ensure safety. They may be the best way to guard against lawsuits, but they are probably the least effective means to achieve safety from a human factors viewpoint.

  5. Consider which behaviors are acceptable, which errors are likely, and what to do about them. It is better to design robust systems that tolerate human variability than expect people to be error-free zombie automatons. If automation is indicated, keep the operator knowledgeable about what the automation procedures allow humans to take over if the automation fails, and engender some responsibility for doing this. Do not be too quick to blame the operators closest to the apparent error occurrence. Tilt toward blaming the system, and be willing to look for latent errors.
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