No Such Thing As Human Error
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Sources Of Error In Experiments
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Types Of Errors In Experiments
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THE ACM1 In 1988, the Soviet Union's Phobos 1 satellite was lost on its way to Mars. Why? According to Science magazine, "not long after the launch, a ground controller omitted
Source Of Error Definition
a single letter in a series of digital commands sent to the spacecraft. sources of error in measurement And by malignant bad luck, that omission caused the code to be mistranslated in such a way as to trigger
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the test sequence" (the test sequence was stored in ROM, but was intended to be used only during checkout of the spacecraft while on the ground) [7]. Phobos went into a tumble from https://www.linkedin.com/pulse/20140414212456-12181762-human-error-no-bad-design which it never recovered. What a strange report. "Malignant bad luck"? Why bad luck: why not bad design? Wasn't the problem the design of the command language that allowed such a simple deviant event to have such serious consequences. The effects of electrical noise on signal detectability, identification, and reliability are well known. Designers are expected to use error-detecting and correcting codes. Suppose interference from known http://www.jnd.org/dn.mss/commentary_human_er.html sources of electromagnetic noise had corrupted the signal to Phobos. We would not blame the ground controllers: we would say that the system designers did not follow standard engineering practice, and we would reconsider the design of the system so as to protect against this problem in the future. People err. That is a fact of life. People are not precision machinery designed for accuracy. In fact, we humans are a different kind of device entirely. Creativity, adaptability, and flexibility are our strengths. Continual alertness and precision in action or memory are our weaknesses. We are amazingly error tolerant, even when physically damaged. We are extremely flexible, robust, and creative, superb at finding explanations and meanings from partial and noisy evidence. The same properties that lead to such robustness and creativity also produce errors. The natural tendency to interpret partial information -- although often our prime virtue -- can cause operators to misinterpret system behavior in such a plausible way that the misinterpretation can be difficult to discover. Quite a lot is known about human performance and the way it applies to system interaction [1]. Several classes of human error have been identified and studied
cause accidents? Yes, but we need to know what led to the error: in the majority of instances it is inappropriate design of equipment or procedures.It is time to launch http://www.jnd.org/dn.mss/human_error_no_bad.html a revolution, time to insist on a people-centered approach to technology.On April 8, 2014, theNew York Timesheadlined a story about a U.S. National Transportation Safety Board (NTSB) report on the tragic incident of January 2013 when a ferry boat rammed a pier, injuring 80 people, 4 seriously. The headline stated "Captain and Design Faulted in East River Ferry Crash." The headline was wrong. The NTSB got of error it right. Here is what Deborah Hersman, chair of the bureau, wrote:Yes, our report identified that the final error was made by the Captain on the day of the accident, but the first vulnerabilities were designed into the system years before. Accidents, like a fraying rope, are always a series of missed opportunities, but the blame typically falls on the final strand in a rope that breaks sources of error - often it is the human being.(From the prepared remarks by Deborah Hersman, chair of NTSB, April 8, 2014.)Hersman got it right with her elegant, final statement. Bad design and procedures lead to breakdowns where, eventually the last link is a person who gets blamed, and punished.It's an oft-repeated story. A tragic accident occurs where people are injured or killed. An investigation starts, determined to find the cause. Eventually it discovers the culprit: a nurse misprogrammed an infusion pump, or the technician entered the wrong dosage, or the pilot entered the wrong code into the navigation equipment, or the ship's captain failed to take the correct action. Ahah! Human error. Punish the culprits. Later, when a similar problem happens, another person will be blamed.Over 90% of industrial accidents are blamed on human error. You know, if it was 5%, we might believe it. But when it is virtually always, shouldn't we realize that it is something else?There were multiple issuescontributing to the ferry accident, but one of the most critical was poor design of the controls that led to the well known and avoidable condition called "mode error." Couple this with NTSB's identification of the lack