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analytic methods still need to be improved to better manage human error.
Kirwan, B. (1998). Human error identification techniques for risk assessment of high risk
systems. Part 1: Review and evaluation of techniques. Applied Ergonomics, 29(3), 157-177.
This first part of a two part paper outlines thirty-eight approaches to error identification. They are
categorized by the type of error identification approach used and then they are critiqued by a
broad range of criteria. Trends and research needs are noted along with the identification of
viable and non-viable techniques. Three major components to an error are broken down. The first
component is the external error mode. This refers to the external manifestation of the error. The
second component is the performance shaping factors. These influence the likelihood of an error
occurring. The third component is the psychological error mechanism. This is the internal
manifestation of the error. The authors go on to recognize seven major error types that appear to
be of interest in current literature. These are slips and lapses, cognitive errors (diagnostic and
decision-making errors), errors of commission, rule violations, idiosyncratic errors, and software
programming errors. In order to show the general orientation of form of each error identification
technique, five broad classifications have been developed. These include taxonomies,
psychologically based tools, cognitive modeling tools, cognitive simulations, and reliabilityoriented
tools. The different approaches were also classified by their analytic method. These
methods are the checklist-based approaches, flowchart-based approaches, group-based
approaches, cognitive psychological approaches, representation techniques, cognitive
simulations, task analysis linked techniques, affordance-based techniques, error of commission
identification techniques, and crew interactions and communications. Ten important criteria to
evaluate the different techniques are laid out. The criteria are comprehensiveness of human
behavior, consistency, theoretical validity, usefulness, resources (actual usage, training time
required, requirement of an expert panel), documentability, acceptability (usage to date,
availability of technique), HEI output quantifiability, life cycle stage applicability, and primary
objective of the technique. Some main techniques are identified which could be useful for
general practice, but it is pointed out that no single technique is sufficient for all of a
practitioner’s need. It is suggested that a framework-based or toolkit-based approach would be
most beneficial.
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Kirwan, B. (1998). Human error identification techniques for risk assessment of high risk
systems. Part 2: Towards a framework approach. Applied Ergonomics, 29(5), 299-318.
This second of a series of papers describes a framework-based and a toolkit-based approach as a
human error identification approach in nuclear power and reprocessing industries. Advantages
and disadvantages are considered. Framework approaches try to deal with all human error types
in an integrative way by using a wide array of tools and taxonomies that have been found to be
effective. The Human Error and Recovery Assessment system (HERA) is a framework approach
that is outlined in this paper. The HERA system is a document and a prototype software package.
The paper only describes in detail the procedure for skill and rule based error identification. The
document is the formal system and has main modules or functional sections. One such main
module is the scope analysis and critical task identification. This module deals with factors to
consider, logistical and otherwise, along with phases of operations to look at. A second module is
task analysis. Initial task analysis and Hierarchical Task Analysis are the two major forms of task
description that are used and described. A third module is skill and rule based error
identification. For this module, nine error identification checklists are used that may have some
over-lapping. These checklists are explained in some detail and include mission analysis,
operations level analysis, goals analysis, plans analysis, error analysis, performance shaping
factor based analysis, psychological error mechanism based analysis, Human Error Identification
in Systems Tool (HEIST) analysis, and human error HAZOP. The five remaining modules that
are not explained in detail are diagnostic and decision-making error identification, error of
commission analysis, rule violation error identification, teamwork and communication error
identification, and integration issues. The toolkit framework approach seeks to ensure that all
relevant error types are discovered by using several existing techniques. It is also pointed out that
　
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