James Reason: Różnice pomiędzy wersjami

Wersja z 10:42, 22 sie 2022

• two ways. 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.--Dwa podejścia do problemu 
• 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.--Podejście praktyczne i podejście teoretyczne
• human error studies
• two traditions of research: the natural science and engineering (or cognitive science) approaches.
• three basic error types: skill-based slips and lapses, rule-based mistakes and knowledge-based mistakes.
• 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.--Kryteria odróżniania typów błędów
• active errors and latent errors
• The former, usually associated with the performance of ‘front-line’ operators (pilots, control room crews, and the like), have an immediate impact upon the system. The latter, 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.
• 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.--Pesymistyczna konkluzja niedoprzewidzenia są interakcje poszczególnych przyczyn i możliwe wynikające stąd błędy i katastrofy
• 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.--Przyczyny wzrostu zainteresowania badaniami nad błędami
• Ernst Mach (1905) put it well: “Knowledge and error flow from the same mental sources, only success can tell the one from the other.”--Mach
• 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.--Teza książki, wpływ cybernetyki
• 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.--Umiejętność popełnienia błędu zapewnia człowiekowi przewagę nad innymi urządzeniami obliczeniowymi, polegającą na zdolności do upraszczania skomplikowanych zadań
• A knowledge base that contains specialised ‘theories’ rather than isolated facts preserves meaningfulness, but renders us liable to confirmation bias.--Confirmation bias
• predictable error
• variable and constant errors.
• 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.
• 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.--Jednoznaczność w ocenie wielkości błędu
• 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
• our theory in A’s case, that he has accurate sights but a shaky hand
• 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.
• Were the actions directed by some prior intention?Did the actions proceed as planned?Did they achieve their desired end?
• 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).--Kategoria błędu dotyczy jedynie czynności intencjonalnych
• 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--Definicja mistake
• “If the intention is not appropriate, this is a mistake. If the action is not what was intended, this is a slip.”--Mistake I slip
• 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).--Jw
• 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.--Robocza definicja błędu 
• 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.--Definicja pomyłki
• 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.
• three levels at which classifications are attempted: the behavioural, contextual and conceptual levels. These correspond approximately to the “What?”, “Where?” and “How?” questions about human errors.--Trzy poziomy kategoryzacji błędów
• error types and error forms.
• 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.
• planning, storage and execution
• 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.
• and knowledge-based levels of performance as described by Rasmussen (1983).
• Table l.l. Classifying the primary error types according to the cognitive stages at which they occur.Cognitive stagePrimary error typePlanningMistakesStorageLapsesExecutionSlips
• Error forms
• 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.
• similarity and frequency biases--Przykłady form 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--Kwestionariusz o popełnieniu przez siebie błędów
• 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)
• Broadbent’s stress-vulnerability hypothesis:--W stresie popełniamy więcej błędów
• relatively high levels of cognitive failure in normal everyday life are associated with increased vulnerability to externally imposed stresses.
• 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.--Błąd jest spowodowany nie tyle przez stres co przez pewne style zarządzania poznawczego
• the Stroop effect
• Error is intimately bound up with the notion of intention. The term ‘error’ can only be meaningfully applied to planned actions that fail to achieve their desired consequences without the intervention of some chance or unforeseeable agency.--Warunkiem koniecznym błędu jest intencja
• Two basic error types were identified: slips (and lapses), where the actions do not go according to plan, and mistakes, where the plan itself is inadequate to achieve its objectives.--Dwa podstawowe typy błędów: wypaczenia i omyłki 
• Errors may be classified at any one of three levels: behavioural, contextual and conceptual.--Trzy poziomy klasyfikacji błędu
• Sully’s Illusions
• 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:(a) False recollections to which there correspond no real events or personal history.(b) Recollections that misrepresent the manner of the happening of real events.(c) 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 first became aware of the meaningfulness of certain everyday slips and lapses in 1896.
• The Psychopathology of Everyday Life
• 1904
• Meringer & Mayer, 1895--Pomyłki językowe
• In 1890, after 12 years of labour, William James completed 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.
• Munsterberg’s
• unreliability of eye-witness testimony.
• On the Witness Stand: Essays on Psychology and Crime (1908),
• 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