Table Judged Reasons for Failure in Events Cited 22 XIV




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3.0 FAILURE EVENTS IN OTHER TRANSPORTATION SYSTEMS 11


3.1 Royal Majesty Grounding (over-reliance on automation, lack of failure awareness) 11

3.2 Herald of Free Enterprise Sinking off Zeebrugge, Netherlands (poor management planning) 11

3.3 BMW 7 Series iDrive Electronic Dashboard (designer gadget fantasy gone wild) 12

3.4 Milstar Satellite Loss (poor assumptions and lack of design coordination) 12

3.5 Failed Ariane Liftoff (poor assumptions in anticipating of software requirement) 12

3.6 Solar Heliospheric Observatory (failure to communicate a procedure change to operators) 12

4.0 FAILURE EVENTS IN PROCESS CONTROL SYSTEMS 13


4.1 Bhopal, India, Union Carbide Leak (multiple failures in design, maintenance, and management) 13

4.2 Nuclear Meltdown at Three Mile Island (failures in design, procedures, management [including maintenance], training, and regulation) 13

4.3 Failure in British Chemical Plant (poor anticipation of unsafe interactions during design) 14

4.4 Uncontrolled Chain Reaction at Japanese Breeder Reactor (operators’ shortcut of recommended safety procedures) 14

4.5 Observed Dysfunction in Steel Plant Blast Furnace Department (poor communication regarding authority) 14

5.0 FAILURE EVENTS IN OTHER SYSTEMS 17


5.1 The Florida Butterfly Ballot (poor interface design, lack of usability testing) 17

5.2 Emergency MRI Oxygen Bottle Kills Child (lack of anticipation of critical safety requirements) 17

5.3 Production of New Salk Vaccine at Cutter Labs (rush to scale up production precluded precautionary care) 17

5.4 Patient Morphine Overdose from Infusion Pump (nurses’ complaints about programming disregarded) 18

5.5 Olympic Swim Meet Scoring Device that Could Not Be Altered (lack of flexibility in design and systems management) 18

5.6 Counting of Instruments and Sponges in Complex Surgeries (lack of appreciation for workload/distraction effects) 18

5.7 VCR Remote Control (technology overkill) 19

6.0 LESSONS LEARNED FROM HUMAN AUTOMATION FAILURES 21


6.1 Degani’s Summary Observations: Another Set of Causal and Remedial Considerations 23

6.2 Awareness of the Problems 24

6.3 Function Allocation 25

6.4 Levels of Automation 26

4. ---executes that suggestion if the human approves, or 26

5. ---allows the human a restricted time to veto before automatic execution, or 26

6. ---executes automatically, then necessarily informs the human, or 26

7. ---executes automatically and informs the human only if asked. 26

8. The computer selects, executes, and ignores the human. 26

6.5 Characteristic Biases of Human Decision-Makers 26

6.6 Human Controller’s Mental Model and/or Automatic Control “Model” of Process: Divergence from Reality 28

6.7 Undermonitoring: Over-reliance on Automation, and Trust 28

6.8 Mystification and Naive Trust 29

6.9 Remedies for Human Error 30

6.10 Can Behavioral Science Provide Design Requirements to Engineers? 30

6.11 The Blame Game: The Need to Evolve a Safety Culture 31

6.12 Concluding Comment 32

7.0 REFERENCES 33

8.0 ACKNOWLEDGMENTS 37


List of Tables

Table 1. Judged Reasons for Failure in Events Cited 22




1.0INTRODUCTION AND SCOPE


The purpose of this review is to consider a variety of failure events where human users interacted with automation, some sophisticated and some not, and to suggest lessons learned from these experiences. Also included are caveats identified in research literature on human-automation interactions that can be applied to design of the Next Generation Air Transportation System (NGATS).


Some events in our sample are failures involving aircraft; others are human interactions with devices in other domains. In almost every case it is not random, unexplainable machine failure or human failure. Rather, it is poor human-machine system design from a human factors perspective: circumstances that are preventable. And while some of these failures have complex causal explanations, most were caused by relatively simple elements of hardware, software, procedure design, or training that were overlooked.


Several accidents not automation-related are included at the end to help make the point that serious consequences can result from simple human user misjudgments in interaction with the physical environment.


Each of the brief summaries was paraphrased from the much longer reports cited. Individual references are listed in parentheses after each heading. These references contain background information and sometimes a colorful description of the unfolding events. Following the failure events summaries are lessons learned and important caveats identified from the literature.

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