Human Error Contribution in Collision and Grounding of Oil Tankers

The purpose of this article is to present a quantitative analysis of the human failure contribution in the collision and/or grounding of oil tankers, considering the recommendation of the ""Guidelines for Formal Safety Assessment"" of the International Maritime Organization. Initially, the employed methodology is presented, emphasizing the use of the technique for human error prediction to reach the desired objective. Later, this methodology is applied to a ship operating on the Brazilian coast and, thereafter, the procedure to isolate the human actions with the greatest potential to reduce the risk of an accident is described. Finally, the management and organizational factors presented in the ""International Safety Management Code"" are associated with these selected actions. Therefore, an operator will be able to decide where to work in order to obtain an effective reduction in the probability of accidents. Even though this study does not present a new methodology, it can be considered as a reference in the human reliability analysis for the maritime industry, which, in spite of having some guides for risk analysis, has few studies related to human reliability effectively applied to the sector.

A study on human error in the interaction with the computer systems

The term human factor is used by professionals of various fields meant for understanding the behavior of human beings at work. The human being, while developing a cooperative activity with a computer system, is subject to cause an undesirable situation in his/her task. This paper starts from the principle that human errors may be considered as a cause or factor contributing to a series of accidents and incidents in many diversified fields in which human beings interact with automated systems. We propose a simulator of performance in error with potentiality to assist the Human Computer Interaction (HCI) project manager in the construction of the critical systems. © 2011 Springer-Verlag.

Literary blunders : a chapter in the "History of human error" /

Mode of access: Internet.

Literary blunders : a chapter in the "History of human error." /

Includes bibliographical references and index.

Identification of factors associated with diagnostic error in primary care.

BACKGROUND Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason's taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. METHODS Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician's initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians' perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. DISCUSSION This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.

An Extended Hierarchical Task Analysis for Error Prediction in Medical Devices

This paper introduces an extended hierarchical task analysis (HTA) methodology devised to evaluate and compare user interfaces on volumetric infusion pumps. The pumps were studied along the dimensions of overall usability and propensity for generating human error. With HTA as our framework, we analyzed six pumps on a variety of common tasks using Norman’s Action theory. The introduced method of evaluation divides the problem space between the external world of the device interface and the user’s internal cognitive world, allowing for predictions of potential user errors at the human-device level. In this paper, one detailed analysis is provided as an example, comparing two different pumps on two separate tasks. The results demonstrate the inherent variation, often the cause of usage errors, found with infusion pumps being used in hospitals today. The reported methodology is a useful tool for evaluating human performance and predicting potential user errors with infusion pumps and other simple medical devices.

Human factors of driver-vehicle interaction in the IVHS environment. Final report.

National Highway Traffic Safety Administration, Washington, D.C.

Computational Foundations for Safe and Efficient Human-Robot Collaboration in Assembly Cells

Human and robots have complementary strengths in performing assembly operations. Humans are very good at perception tasks in unstructured environments. They are able to recognize and locate a part from a box of miscellaneous parts. They are also very good at complex manipulation in tight spaces. The sensory characteristics of the humans, motor abilities, knowledge and skills give the humans the ability to react to unexpected situations and resolve problems quickly. In contrast, robots are very good at pick and place operations and highly repeatable in placement tasks. Robots can perform tasks at high speeds and still maintain precision in their operations. Robots can also operate for long periods of times. Robots are also very good at applying high forces and torques. Typically, robots are used in mass production. Small batch and custom production operations predominantly use manual labor. The high labor cost is making it difficult for small and medium manufacturers to remain cost competitive in high wage markets. These manufactures are mainly involved in small batch and custom production. They need to find a way to reduce the labor cost in assembly operations. Purely robotic cells will not be able to provide them the necessary flexibility. Creating hybrid cells where humans and robots can collaborate in close physical proximities is a potential solution. The underlying idea behind such cells is to decompose assembly operations into tasks such that humans and robots can collaborate by performing sub-tasks that are suitable for them. Realizing hybrid cells that enable effective human and robot collaboration is challenging. This dissertation addresses the following three computational issues involved in developing and utilizing hybrid assembly cells: - We should be able to automatically generate plans to operate hybrid assembly cells to ensure efficient cell operation. This requires generating feasible assembly sequences and instructions for robots and human operators, respectively. Automated planning poses the following two challenges. First, generating operation plans for complex assemblies is challenging. The complexity can come due to the combinatorial explosion caused by the size of the assembly or the complex paths needed to perform the assembly. Second, generating feasible plans requires accounting for robot and human motion constraints. The first objective of the dissertation is to develop the underlying computational foundations for automatically generating plans for the operation of hybrid cells. It addresses both assembly complexity and motion constraints issues. - The collaboration between humans and robots in the assembly cell will only be practical if human safety can be ensured during the assembly tasks that require collaboration between humans and robots. The second objective of the dissertation is to evaluate different options for real-time monitoring of the state of human operator with respect to the robot and develop strategies for taking appropriate measures to ensure human safety when the planned move by the robot may compromise the safety of the human operator. In order to be competitive in the market, the developed solution will have to include considerations about cost without significantly compromising quality. - In the envisioned hybrid cell, we will be relying on human operators to bring the part into the cell. If the human operator makes an error in selecting the part or fails to place it correctly, the robot will be unable to correctly perform the task assigned to it. If the error goes undetected, it can lead to a defective product and inefficiencies in the cell operation. The reason for human error can be either confusion due to poor quality instructions or human operator not paying adequate attention to the instructions. In order to ensure smooth and error-free operation of the cell, we will need to monitor the state of the assembly operations in the cell. The third objective of the dissertation is to identify and track parts in the cell and automatically generate instructions for taking corrective actions if a human operator deviates from the selected plan. Potential corrective actions may involve re-planning if it is possible to continue assembly from the current state. Corrective actions may also involve issuing warning and generating instructions to undo the current task.

Terminologia de incidentes com medicamentos no contexto hospitalar

Incidentes com medicamentos geram problemas aos pacientes e custos adicionais ao sistema de saúde. A variedade de termos utilizada para comunicá-los propicia divergências nos resultados de pesquisas e confundem notificadores. Objetivou-se revisar os termos utilizados para descrever estes incidentes confrontando-os com as conceituações/definições oficiais disponíveis. Pesquisaram-se as bases PubMed, MEDLINE, IPA e LILACS para selecionar estudos publicados entre janeiro de 1990 e dezembro de 2005. Selecionaram-se 33 publicações. Verificou-se que a terminologia supranacional recomendada para descrever incidentes com medicamentos é insuficiente, mas que há consenso de uso das expressões em função do gênero do incidente. O termo Reação Adversa a Medicamento é mais utilizado quando não se verifica intencionalidade. A expressão Evento Adverso a Medicamento foi mais usada quando se descreviam incidentes durante a hospitalização; e Problema Relacionado a Medicamento foi mais utilizada em estudos que avaliaram atenção/cuidados farmacêuticos (uso/falta do medicamento). Ainda assim, a linha divisória entre essas três categorias não é clara e simples. Futuros estudos das relações entre as categorias e investigações multidisciplinares sobre erro humano podem subsidiar a proposição de novas conceituações

Research on evaluation system of emergency disposal plan for power plant incidents

This paper starts with the analysis of the unusual inherence mechanism, from two aspects: accumulating and human error. We put forward twelve factors affected the decision of the emergency treatment plan in practice and summarized the evaluation index system combining with literature data. Then we screened out eighteen representative indicators by used the FDM expert questionnaire in the first phase. Hereafter, we calculated the weight of evaluation index and sorted them by the FAHP expert questionnaire, and came up with the frame of the evaluation rule by combined with the experience. In the end, the evaluation principles are concluded.

Colapsos de pontes: lições aprendidas

Trabalho Final de Mestrado para obtenção do grau de Mestre em Engenharia Civil na Área de Especialização em Estruturas