James Reason

Studia nad ludzkim błędem

• human error studies
• Dwa podejścia do problemu błędu:
  • "The topic can be treated in a broad but shallow fashion, aiming at a wide though superficial coverage of many well-documented error types.
  • Or, an attempt can be made to carve out a narrow but relatively deep slice, trading comprehensiveness for a chance to get at some of the more general principles of error production."
• Podejście praktyczne i podejście teoretyczne: "like to collect, cultivate and categorise errors, practitioners are more interested in their elimination and, where this fails, in containing their adverse effects by error-tolerant designs."
• two traditions of research: the natural science and engineering (or cognitive science) approaches.
• three basic error types:
  1. skill-based slips and lapses,
  2. rule-based mistakes and
  3. knowledge-based mistakes.
• Kryteria odróżniania typów błędów: "These three types may be distinguished on the basis of several dimensions: activity, attentional focus, control mode, relative predictability, abundance in relation to opportunity, situational influences, ease of detection and relationship to change."
• active errors and latent errors
  • active errors: "usually associated with the performance of ‘front-line’ operators (pilots, control room crews, and the like), have an immediate impact upon the system. "
  • latent errors: "most often generated by those at the ‘blunt end’ of the system (designers, high-level decision makers, construction crews, managers, etc.), may lie dormant for a long time, only making their presence felt when they combine with other ‘resident pathogens’ and local triggering events to breach the system’s defences."
• Pesymistyczna konkluzja - nie do przewidzenia są interakcje poszczególnych przyczyn i możliwe wynikające stąd błędy i katastrofy: "The final note is a rather pessimistic one. Engineered safety devices are proof against most single failures, both human and mechanical. As yet, however, there are no guaranteed technological defences against either the insidious build-up of latent failures within the organisational and managerial spheres or their adverse (and often unforeseeable) conjunction with various local triggers. While cognitive psychology can tell us something about an individual’s potential for error, it has very little to say about how these individual tendencies interact within complex groupings of people working in high-risk systems. And it is these collective failures that represent the major residual hazard."
• Przyczyny wzrostu zainteresowania badaniami nad błędami, katastrofy spowodowane przez człowieka: "the Tenerife runway collision in 1977, Three Mile Island two years later, the Bhopal methyl isocyanate tragedy in 1984, the Challenger and Chernobyl disasters of 1986, the capsize of the Herald of Free Enterprise, the King’s Cross tube station fire in 1987 and the Piper Alpha oil platform explosion in 1988."
• Mach: "Ernst Mach (1905) put it well: “Knowledge and error flow from the same mental sources, only success can tell the one from the other.”"
• Teza książki, wpływ cybernetyki: "A central thesis of this book is that the relatively limited number of ways in which errors actually manifest themselves is inextricably bound up with the ‘computational primitives’ by which stored knowledge structures are selected and retrieved in response to current situational demands."
• Umiejętność popełnienia błędu zapewnia człowiekowi przewagę nad innymi urządzeniami obliczeniowymi, polegającą na zdolności do upraszczania skomplikowanych zadań: "And it is just these processes that confer upon human cognition its most conspicuous advantage over other computational devices: the remarkable ability to simplify complex informational tasks."
• Confirmation bias: "A knowledge base that contains specialised ‘theories’ rather than isolated facts preserves meaningfulness, but renders us liable to confirmation bias."

Błąd zmienny i błąd stały

• predictable error: czy można przewidzieć błąd?
• variable and constant errors, A-trafia wokół 10, B trafia stale w jedno miejsce w 8: "A’s pattern exhibits no constant error, only a rather large amount of variable error. B shows the reverse: a large constant error, but small variable error. In this example, the variability is revealed by the spread of the individual shots, and provides an indication of the rifleman’s consistency of shooting."
• Jednoznaczność w ocenie wielkości błędu: "If we should rely only on their respective scores, then A would appear the better shot, achieving a total of 88 to B’s 61. But it is obvious from the groupings that this is not the case. A more acceptable view would be that A is a rather unsteady shot with accurately aligned sights, while B is an expert marksman whose sights are out of true."
• bias to błąd stały: "in B’s case, we have a theory that will account for the precise nature of his constant error, namely, that he is an excellent shot with biased sights"
• the three major elements in the production of an error: the nature of the task and its environmental circumstances, the mechanisms governing performance and the nature of the individual.
• "An adequate theory, therefore, is one that enables us to forecast both the conditions under which an error will occur, and the particular form that it will take."

Intencja

• kryteria klasyfikacji działań
  1. Were the actions directed by some prior intention?
     • no: spontaneous or subsidiary action (intention in action); involuntary or nonintentional action (no intention in action);
  2. Did the actions proceed as planned?
     • unintentional action (slip, collapse)
  3. Did they achieve their desired end?
     • no: intentional but mistaken action (inappropriate intention)
     • yes: successful action
• Kategoria błędu dotyczy jedynie czynności intencjonalnych: "Thus the term error can only be applied to intentional actions. It has no meaning in relation to nonintentional behaviour because error types depend critically upon two kinds of failure: the failure of actions to go as intended (slips and lapses) and the failure of intended actions to achieve their desired consequences (mistakes)."

Mistake vs. slip

• Definicja mistake: "Even when the intended actions proceed as planned, they can still be judged as erroneous if they fail to achieve their intended outcome. In this case, the problem resides in the adequacy of the plan rather than in the conformity of its constituent actions to some prior intention. Errors of this kind are termed mistakes"
• Mistake vs. slip: "“If the intention is not appropriate, this is a mistake. If the action is not what was intended, this is a slip.”"
• Jw.: "Mistakes involve a mismatch between the prior intention and the intended consequences. For slips and lapses, however, the discrepancy is between the intended actions and those that were actually executed."
• Jw: "planning failures (mistakes) and execution failures (slips and lapses)."
• Robocza definicja błędu: "Error will be taken as a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency."
• Definicja slips i lapses: "Slips and lapses are errors which result from some failure in the execution and/or storage stage of an action sequence, regardless of whether or not the plan which guided them was adequate to achieve its objective."
• slip vs. lapse: "Whereas slips are potentially observable as externalised actions-not-as-planned (slips of the tongue, slips of the pen, slips of action), the term lapse is generally reserved for more covert error forms, largely involving failures of memory, that do not necessarily manifest themselves in actual behaviour and may only be apparent to the person who experiences them."
• definicja mistake: "Mistakes may be defined as deficiencies or failures in the judgemental and/or inferential processes involved in the selection of an objective or in the specification of the means to achieve it, irrespective of whether or not the actions directed by this decision-scheme run according to plan."

Trzy poziomy klasyfikacji

• Trzy poziomy kategoryzacji błędów: "three levels at which classifications are attempted:
  1. behavioural level (What?)
  2. contextual level (What?)
  3. conceptual level (How?)

Error types

• "The term error type relates to the presumed origin of an error within the stages involved in conceiving and then carrying out an action sequence."
• mistakes "can be further subdivided into (a) failures of expertise, where some preestablished plan or problem solution is applied inappropriately and (b) a lack of expertise, where the individual, not having an appropriate ‘off-the-shelf routine, is forced to work out a plan of action from first principles, relying upon whatever relevant knowledge he or she currently possesses."
• knowledge-based levels of performance as described by Rasmussen (1983).

Classifying the primary error types according to the cognitive stages at which they occur.

Cognitive stage	error type
Planning	Mistakes
Storage	Lapses
Execution	Slips

Error forms

• error forms vs. error types: "Whereas error types are conceptually tied to underlying cognitive stages or mechanisms, error forms are recurrent varieties of fallibility that appear in all kinds of cognitive activity, irrespective of error type."
• Przykłady form błędów: similarity and frequency biases
• Kwestionariusz o popełnieniu przez siebie błędów: "Responses to questionnaire items are generally positively correlated. Thus, those people who confess to being particularly liable to one kind of cognitive failure (e.g., memory lapses) also tend to report a high degree of susceptibility to other types as well (e.g., action slips), and conversely"
• "This suggests that error proneness is not specific to any one cognitive domain, but operates more or less uniformly across all types of mental function (see Broadbent et al., 1982; Reason & Mycielska, 1982)"
• W stresie popełniamy więcej błędów, Broadbent’s stress-vulnerability hypothesis: "relatively high levels of cognitive failure in normal everyday life are associated with increased vulnerability to externally imposed stresses."
• Błąd jest spowodowany nie tyle przez stres, co przez pewne style zarządzania poznawczego: "The evidence so far assembled suggests that it is not so much that stress induces a high rate of cognitive failure, but that certain styles of cognitive management can lead to both absent-mindedness and to the inappropriate matching of coping strategies to stressful situations."
• the Stroop effect (trudność w nazywaniu kolorów, jeśli są użyte do zapisu nazw innych kolorów)

Sully i iluzje

• James Sully, Illusions. A Psychological Study, 1882
• These four modes of cognition—external perception, introspection, memory and belief—constituted the major dimension of Sully’s error taxonomy.
• three major classes of memory illusions:
  1. False recollections to which there correspond no real events or personal history.
  2. Recollections that misrepresent the manner of the happening of real events.
  3. Recollections that falsify the date of the events remembered.
• "For each of these, there is a corresponding perceptual analogue: (a) perceptions for which there are no external counterparts (e.g., ocular spectra, sensations of light and hallucinations); (b) perceptions that distort the shape of the external object (e.g., the effects of haze and refracting media) and (c) perceptions that falsify size and distance (e.g., when clear air causes distant mountains to seem far closer than they are, or when intervening ‘clutter’ makes objects appear more distant)."

Freud i psychoanaliza

• "Freud first became aware of the meaningfulness of certain everyday slips and lapses in 1896."
• The Psychopathology of Everyday Life, 1904
• Pomyłki językowe: Meringer & Mayer, 1895
• William James, The Principles of Psychology: "some unparalleled descriptions of everyday cognitive failings, they also contained, in the chapters on habit, memory and will, nearly all the necessary elements of a theory of human error."
• Hugo Munsterberg, On the witness stand (1908): unreliability of eye-witness testimony.
• In 1905, Joseph Jastrow, professor of psychology at the University of Wisconsin, published an analysis of some 300 ‘lapses of consciousness’ collected from his students. This was the first systematic attempt to investigate slips of action (as distinct from slips of the tongue) and stressed the necessity of some kind of attentional intervention in order to prevent action sequences from deviating along habitual but unintended routes

The Gestalt tradition

• Max Wertheimer, Wolfgang Kohler and Kurt Koffka
• Kurt Lewin, Frederic Bartlett

Schemata

• schemata: "Bartlett (1932) invoked the notion of schema (schemata in the plural) to explain systematic errors that were apparent in the recall of pictorial and textual material. He found that reproductions made from memory were more regular, more meaningful and more conventionalised than the original stories or drawings."
• fundamental aspects of schemata
  1. they were unconscious mental structures (“schema are active, without any awareness at all”),
  2. that they were composed of old knowledge (“They are masses of organised past experiences.”)
  3. that long-term memory comprised active knowledge structures rather than passive images.
• rekonstrukcja raczej niż reprodukcja wspomnień: "Thus, schemata reconstructed rather than reproduced past experiences. And this process leads to certain predictable biases in remembering, due in large part to “the tendency to interpret presented material in accordance with the general character of earlier experience.”
• Łatwiej zapamiętujemy przez słuch niż przez wzrok: "the latter part of a sequence presented auditorally is better recalled than one presented visually (Von Sybel, 1909)"
• "Common to both theories is the idea that schemata are high-level knowledge structures that contain informational ‘slots’ or variables. Each slot will only accept a particular kind of information. If the current inputs from the world fail to supply specific data to fill these slots, they take on ‘default assignments’: stereotypical values derived from past transactions with the world. As will be seen in later chapters, this idea of reverting to ‘default assignments’ is central to the main thesis of this book."
• Typowe obiekty rozpoznajemy na podstawie schematów wypełniając puste miejsca: "In Minsky’s terminology, commonly encountered visual environments, such as rooms, are represented internally by a frame, containing nodes for standard features such as walls, floors, ceilings, windows and the like, and slots for storing the particular items relating to a certain kind of room."
• Rumelhart defined schemata as “data structures for representing generic concepts stored in memory” (Rumelhart & Ortony, 1977, p. 101)
• Współczesne warianty teorii schematów: "scripts (Abelson, 1976), plans (Neisser, 1976), prototypes (Cantor & Mischel, 1977) and personae (Nisbett & Ross, 1980)."

Bounded rationality

• Subjective Expected Utility Theory: wyboru dokonuje w pełni racjonalny podmiot
• hindsight bias: "knew it all along"
• Simon, 1975, bounded rationality: "The capacity of the human mind for formulating and solving complex problems is very small compared with the size of the problems whose solution is required for objectively rational behaviour in the real world—or even for a reasonable approximation of such objective rationality."
• satisficing behaviour: "the tendency to settle for satisfactory rather than optimal courses of action"
• "people rely on a limited number of heuristic principles which reduce the complex tasks of assessing probabilities and predicting values to simpler judgemental operations. In general, these heuristics are quite useful, but sometimes lead to severe and systematic errors” (Tversky & Kahneman, 1974).
• dwie ważne heurystyki:
  • the representativeness heuristic (like causes like)
  • the availability heuristic (things are judged more frequent the more readily they spring to mind)
• Janis (1972): the groupthink syndrome

Performance level and error types

• generic error-modelling system (GEMS)
• two hitherto distinct areas of error research:
  • slips and lapses, in which actions deviate from current intention due to execution failures and/or storage failures (see Reason, 1979, 1984a, b; Reason & Mycielska, 1982; Norman, 1981; Norman & Shallice, 1980); and
  • mistakes, in which the actions may run according to plan, but where the plan is inadequate to achieve its desired outcome (Simon, 1957, 1983; Wason & Johnson-Laird, 1972; Rasmussen & Jensen, 1974; Nisbett & Ross, 1980; Rouse, 1981; Hunt & Rouse, 1984; Kahneman, Slovic & Tversky, 1982; Evans, 1983).

Relating the three basic error types to Rasmussen’s three performance levels.

Performance level	Error type
Skill-based level	Slips and lapses
Rule-based level	Rule-based mistakes
Knowledge-based level	Knowledge-based mistakes

• Experts, then, have a much larger collection of problem-solving rules than novices.
• human beings are furious pattern matchers.
• Summarising the main headings for the failure modes at each of the three performance levels

Skill-based performance: Slips and lapses

Inattention	Overattention
Double-capture	Omissions
Omissions following interruptions	Repetitions
Reduced intentionality
Reversals
Perceptual confusions
Interference errors

Rule-based performance: mistakes

Misapplication of good rules	Application of bad rules
First exceptions	Encoding deficiencies
Countersigns and nonsigns	Action deficiencies
Informational overload	Wrong rules
Rule strength	Inelegant rules
General rules	Inadvisable rules
Redundancy
Rigidity

Knowledge-based performance: mistakes

Selectivity

Workspace limitations

Out of sight out of mind

Confirmation bias

Overconfidence

Biased reviewing

Illusory correlation

Halo effects

Problems with causality

Problems with complexity

Problems with delayed feed-back

Insufficient consideration of processes in time

Difficulties with exponential developments

Thinking in causal series not causal nets

Thematic vagabonding

Encysting

• deployment bias: to favour previously informative signs rather than the rarer countersigns.
• Luchins and Luchins (1950), Jars Test.
• "To a person with just a hammer, every problem looks like a nail."
• The application of bad rules
  • encoding deficiencies: "of a particular situation are either not encoded at all or are misrepresented in the conditional component of the rule;"
  • action deficiencies: "action component yields unsuitable, inelegant or inadvisable responses."
• three main types of problem configuration
  1. Static configurations: These are problems in which the physical characteristics of the problem space remain fixed regardless of the activities of the problem solver. Examples of this problem type are syllogisms, the Wason card test and cannibals-and-missionaries problems.
  2. Reactive-dynamic configurations: Here, the problem configuration changes as a direct consequence of the problem solver’s actions. Examples are jigsaw puzzles, simple assembly tasks, and the Tower of Hanoi.
  3. Multiple-dynamic configurations: In these problems, the configuration can change both as the result of the problem solver’s activities and, spontaneously, due to independent situational or system factors
• bounded and complex multiple-dynamic problems: "An important distinction here is between bounded and complex multiple-dynamic problems. In the former, the additional variability arises from limited and known sources (e.g., the other player’s moves in a game of chess). In the latter, however, this additional variability can stem from many different sources, some of which may be little understood or anticipated (e.g., coping with nuclear power plant emergencies or managing a national economy)."
• Problemy na poziomie wiedzy: "knowledge-based problem solving were then considered: selecting the wrong features of the problem space, being insensitive to the absence of relevant elements, confirmation bias, overconfidence, biased reviewing of plan construction, illusory correlation, halo effects, and problems with causality, with complexity and with diagnosis in everyday life."
• Typy błędów i formy błędów: "Error types are differentiated according to the performance levels at which they occur. Error forms, on the other hand, are pervasive varieties of fallibility that are evident at all performance levels"

Cognitive underspecification and error form

• formy błędów: error forms are shaped primarily by two factors: similarity and frequency
• Dwa rodzaje form błędów: "These, in turn, have their origins in the automatic retrieval processes— similarity-matching and frequency-gambling—by which knowledge structures are located and their products delivered to consciousness (thoughts, words, images, etc.) or to the outside world (action, speech or gesture)."
• Uogólnienie: "When cognitive operations are underspecified, they tend to default to contextually appropriate, high-frequency responses."
• Frequency biasing
• Przykłady: "form: ‘conventionalization’ (Bartlett, 1932), ‘sophisticated guessing’ (Solomon & Postman, 1952), ‘fragment theory’ (Neisser, 1967), ‘response bias’ (Broadbent, 1967), ‘strong associate substitution’ (Chapman & Chapman, 1973), ‘inert stereotype’ (Luria, 1973), ‘banalization’ (Timpanaro, 1976), ‘strong habit intrusions’ (Reason, 1979) and ‘capture errors’ (Norman, 1981)."
• the computational ‘primitives’ of the cognitive system: "Such fundamental aspects of experience as the degree of likeness between events or objects and their frequency of prior occurrence have been termed intuitive concepts. Similarity and frequency information appear to be processed automatically without conscious effort, or perhaps even without awareness, regardless of age, ability, cultural background, motivation or task instructions"
• "common words are more readily recognised than infrequent ones when presentation is rapid or attenuated"
• "Commonly occurring words tend to have a higher probability of recall than less frequent words."
• underspecification causes the most activated schema to be called to mind first.

Prospective memory

• tu jest przechowywana intencja poprzedzająca działanie: "intention store’ (Harris & Wilkins, 1982; Baddeley & Wilkins, 1984; Harris, 1984)."
• prospective memory, slips and lapses
  • detached intentions (“I intended to close the window as it was cold. I closed the cupboard door instead.”),
  • environmental capture (“I went into my bedroom intending to fetch a book. I took off my rings, looked in the mirror and came out again— without the book.”)
  • multiple sidesteps (“I intended to go to the cupboard under the stairs to turn off the immersion heater. I dried my hands to turn off the switch, but went to the larder instead. After that, I wandered into the living room, looked at the table, went back to the kitchen, and then I remembered my original intention.”)
  • the what-am-I-doing-here experience (“I opened the fridge and stood there looking at its contents, unable to remember what it was I wanted.”)
  • the even more frustrating I-should-be-doing-something-but-I-can’t-remember-what experience

Convergent and divergent searches

• two different kinds of memory search: convergent and divergent searches.
• If a person were to be asked: What has four legs, barks, wags its tail, is usually friendly, has an acute sense of smell, cocks its leg and is called man’s best friend?—there is little doubt that he or she would answer ‘a dog’. If the same person were asked to generate exemplars of the category ‘four-legged animal’, there is also a very strong possibility (see Battig & Montague, 1969) that the response ‘dog’ would occur very early in the output list, probably in the first position.
• Convergent and divergent search processes can be thought of as the extremes of a continuum. At the convergent end, the similarity-matching heuristic is dominant, whereas frequency-gambling prevails at the divergent end

Multiple trace hypothesis

• multiple trace hypothesis, mechanizm funkcjonowania pamięci, empiryczna uzasadnienie wielogłosowości i dialogowości Bachtina: "each encounter with a given item is recorded as an additional trace on a ‘pile’ of like traces (Hintzman, 1976; Hintzman, Nozawa & Irmscher, 1982). According to this notion, frequency information is represented in a privileged analogue form (i.e., by the ‘height’ of the ‘pile’ of like traces). It is also assumed that each individual trace preserves episodic information regarding both the context of the encounter and connections with co-occurrent items."

Bibliografia

• Hugo Munsterberg, On the Witness Stand: Essays on Psychology and Crime (1908)
• James Reason, Human Error, Cambridge: Cambridge University Press
• James Sully, Illusions. A Psychological Study, 1882