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ATHEANA method was demonstrated in a trial application and provided a “proof of concept”
for both the method itself and the principles underlying it.
Danaher, J. W. (1980). Human error in ATC system operations. Human Factors, 22(5),
535-545.
Errors in air traffic control systems are occurring more often as air traffic increases. The author
reviews the FAA’s program that sought to identify and correct causes of system errors which
occur as a result of basic weaknesses inherent in the composite man-machine interface. A system
error was defined as the occurrence of a penetration in the buffer zone that surrounds an aircraft.
A database called the System Effectiveness Information System (SEIS) has been kept to be able
to make summaries of system error data in desired categories. A system error is allowed only one
direct cause, but may have many contributing causes. There are nine cause categories. These are
attention, judgment, communications, stress, equipment, operations management, environment,
procedures, and external factors.
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De Keyser, V., & Woods, D. D. (1990). Fixation errors: failures to revise situation
assessment in dynamic and risky systems. In A. G. Colombo and A. Saiz de Bustamante
(Eds.), Systems reliability assessment (pp. 231-252). Dordrechts, The Netherlands: Kluwer
Academic Publishers.
The paper identifies a major source of human error as being a failure to revise situation
assessment as new evidence becomes available. These errors are called fixation errors and are
identified by their main descriptive patterns. The paper explores ways to build new systems to
reduce this type of error. Fixation occurs when a person does not revise their situation
assessment or course of action in response to one of two things. Either the situation assessment
or course of action has become inappropriate given the actual situation, or the inappropriate
judgment or action persists in the face of opportunities to revise. Three main patterns of behavior
occur during fixation. There is the “Everything but that” pattern, the “This and nothing else”
pattern, and the “Everything is OK” pattern. The authors go on to describe a fixation incident
analysis. The analysis is broken into categories. These are initial judgment and background, the
error, opportunities to revise, neutral observer tests, incident evolution, and revision and
correction.
Diehl, A. E. (1989). Human performance aspects of aircraft accidents. In R. S. Jensen (Ed.),
Aviation psychology (pp. 378-403). Brookfield, VT: Gower Technical.
There is an important relationship between the phenomena of accident generation with the
following investigation process, and the measures that are eventually performed to prevent more
similar accidents from occurring. With this in mind, the author describes three important
elements in accident generation. First, hazards occur when a dangerous situation is detected and
adjusted for. Hazards are common. Second, incidents occur when a dangerous situation isn’t
detected until it almost occurs and an evasive action of some sort is needed. These are infrequent.
Third, accidents occur when a dangerous situation isn’t detected and does occur. These are rare.
Aircraft accident investigation consists of several discrete functions that occur in the following
sequence: fact finding, information analysis, and authority review. It is also important to examine
comparative data sources and mishap data bases. There are also important accident prevention
elements which are to establish procedural safeguards, provide warning devices, incorporate
safety features, and eliminate hazards and risks.
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Dougherty, E. M., Jr., & Fragola, J. R. (1988). Human reliability analysis. New York: John
Wiley & Sons.
A human error taxonomy is discussed that draws heavily from the Rasmussen taxonomy. This is
then used to formulate a conceptual framework of technological risks. The human error
taxonomy is broken down into behavior types (mistakes, slips) and the different parts to error
(modes, mechanisms, causes). The parts of errors are expanded below:
Modes
Misdetection
Misdiagnosis
Faulty decision
Faulty planning
Faulty actions
Mechanisms
False sensations
Attentional failures
Memory lapses
Inaccurate recall
Misperceptions
Faulty judgments
Faulty inferences
Unintended actions
Causes
Misleading
Indicator
Lack of knowledge
Uncertainty
Time stress
Distraction
Physical incapacitation
Excessive force
Human variability
The framework shows that the human being consists of many modules that carry out selected
　
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