دانلود رایگان مقاله تشخیص خطای نهفته

Abstract

Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance.

7. Summary

The aim of the current study has been to advance knowledge on the nature and extent of LED through diary accounts of LED events so that potential ergonomic interventions can be identified. A multi-process approach to systems research was used that combines theories on PM, SAS and the PCM. Additionally, the CFQ was administered to simply affirm that the sample exhibited normal cognitive behaviours associated with skilled workers thus the current findings are likely to be transferrable to other populations of skilled workers. Previously unreported LED events appear to show successful human performance (Safety II) to be effective upon the deliberate review of past tasks within a golden window of two hours of the erroneous act occurring; notably during periods of unfocused attention and whilst working alone in the same or similar sociotechnical environment to that which the error occurred. Several sociotechnical factors associated with LED were studied so that ergonomic interventions could be identified, which are anticipated to enhance LED.