The objective of this panel was to discuss issues critical to the modern practice of science, wit... more The objective of this panel was to discuss issues critical to the modern practice of science, with a specific focus on how we train students to operate within a system that often slows scientific innovation. Chris Brill provided opening remarks to frame the discussion and introduce the panelists. Ben Lawson briefly summarized the most significant problems affecting modern science and how they limit discovery, stifle innovation, and reduce quality. The remaining panelists then provided brief opening remarks in response to Lawson's summary. Specifically, Frank Durso addressed how the current research and funding environments affects student training and career advice. Peter Hancock addressed how risk-averse sponsors and business models prohibit innovative research. Scott Shappell discussed how different Human Factors and Ergonomics (heretofore referenced as HF/E) career paths lead people to and from their roles as scientists. Specifically, he discussed how to prepare students for flexibility in the changing landscape of the business of science. The panel then turned to facilitated discussion with panelists and audience members. Specific themes included the business of science in relation to educational practices, the applied nature of HF/E training within the scientist/practitioner model, and implications of short-term funding schedules on education and research practices. The panel concluded by discussing how HF/E scientists/practitioners may be uniquely qualified to offer potential solutions to the above problems from educational and systemic perspectives.
: As a continuation of our previous work during Operation Desert Shield/Storm, we examined the ef... more : As a continuation of our previous work during Operation Desert Shield/Storm, we examined the effect a fleet exercise has on the work/rest patterns, fatigue, and cognitive performance of F/A-18 aviators. For 10 days during Fleet Exercise 1992, 25 pilots from VFA-81 and VFA-83 completed daily work/rest logs while performing their usual tasks. Subjective measure of fatigue, quality of rest, and sleep need were also collected. A subset of these F/A-18 pilots completed a brief battery of cognitive tasks as soon before flying as possible and again after the flight debrief. As a group, the pilots were adequately rested with little or no problem sleeping, and they operated on a typical work/rest schedule for deployed F/A-18 aviators. However, in some instances during which late night missions were flown, sleep onset was delayed, coupled with shorter sleep periods and additional sleep problems. Several work/ rest and flight related parameters were related to subjective measures of aircrew ...
Studies of offshore and maritime incidents (accidents and near-misses) show that 80% or more invo... more Studies of offshore and maritime incidents (accidents and near-misses) show that 80% or more involve human error. By investigating incidents, we can identify safety problems and take corrective actions to prevent future such events. While many offshore and maritime companies have incident investigation programs in place, most fall short in identifying and dealing with human errors. This paper discusses how to incorporate human factors into an incident investigation program. Topics include data collection and analysis and how to determine the types of safety interventions appropriate to safeguard against the identified risks. Examples are provided from three organizations that have established their own human factors investigation programs.
Proceedings of the Human Factors and Ergonomics Society Annual Meeting
ABSTRACT The objective of this panel was to discuss issues critical to the modern practice of sci... more ABSTRACT The objective of this panel was to discuss issues critical to the modern practice of science, with a specific focus on how we train students to operate within a system that often slows scientific innovation. Chris Brill provided opening remarks to frame the discussion and introduce the panelists. Ben Lawson briefly summarized the most significant problems affecting modern science and how they limit discovery, stifle innovation, and reduce quality. The remaining panelists then provided brief opening remarks in response to Lawson’s summary. Specifically, Frank Durso addressed how the current research and funding environments affects student training and career advice. Peter Hancock addressed how risk-averse sponsors and business models prohibit innovative research. Scott Shappell discussed how different Human Factors and Ergonomics (heretofore referenced as HF/E) career paths lead people to and from their roles as scientists. Specifically, he discussed how to prepare students for flexibility in the changing landscape of the business of science. The panel then turned to facilitated discussion with panelists and audience members. Specific themes included the business of science in relation to educational practices, the applied nature of HF/E training within the scientist/practitioner model, and implications of short-term funding schedules on education and research practices. The panel concluded by discussing how HF/E scientists/practitioners may be uniquely qualified to offer potential solutions to the above problems from educational and systemic perspectives.
This investigation explores flow disruptions observed during cardiothoracic surgery and how they ... more This investigation explores flow disruptions observed during cardiothoracic surgery and how they serve to disconnect anesthesia providers from their primary task. We can improve our understanding of this disengagement by exploring what we call the error space or the accumulated time required to resolve disruptions. Trained human factors students observed 10 cardiac procedures for disruptions impacting the anesthesia team and recorded the time required to resolve these events. Observations were classified using a human factors taxonomy. Of 301 disruptions observed, interruptions (e.g., those events related to alerts, distractions, searching activity, spilling/dropping, teaching moment, and task deviations) accounted for the greatest frequency of events (39.20%). The average amount of time needed for each disruption to be resolved was 48 seconds. Across 49.87 hours of observation, more than 4 hours were spent resolving disruptions to the anesthesia team's work flow. By defining a ...
: The fatigue and cognitive performance deficits associated with sleep loss and stress, like that... more : The fatigue and cognitive performance deficits associated with sleep loss and stress, like that experienced during sustained flight operations and nighttime flying, have motivated the search for effective nonpharmacological countermeasures. The behavioral effects of the potential countermeasure tyrosine, an amino-acid precursor to dopamine and norepinephrine, were examined during an episode of continuous nighttime work involving one night's sleep loss. Volunteers performed nine iterations of a battery of cognitive and subjective tasks for approximately 13 h, beginning at 1930 and ending at 0820 the following morning. Subjects remained awake throughout the day on which the experiment began and were awake for approximately 24 h by the end of testing. Six hours after the start of the experiment, one-half of the subjects received 150 mg/kg tyrosine in a split dose while the other half received a cornstarch placebo in a double-blind procedure. The tracking-task performance of tyros...
Over the last several decades, humans have played a progressively more important causal role in a... more Over the last several decades, humans have played a progressively more important causal role in aviation accidents as aircraft have become more. Consequently, a growing number of aviation organizations are tasking their safety personnel with developing safety programs to address the highly complex and often nebulous issue of human error. However, there is generally no “off-the-shelf” or standard approach for addressing human error in aviation. Indeed, recent years have seen a proliferation of human error frameworks and accident investigation schemes to the point where there now appears to be as many human error models as there are people interested in the topic. The purpose of the present document is to summarize research and technical articles that either directly present a specific human error or accident analysis system, or use error frameworks in analyzing human performance data within a specific context or task. The hope is that this review of the literature will provide practi...
American journal of medical quality : the official journal of the American College of Medical Quality, Jan 25, 2016
The reliability of the Human Factors Analysis and Classification System (HFACS) for classifying r... more The reliability of the Human Factors Analysis and Classification System (HFACS) for classifying retrospective observational human factors data in the cardiovascular operating room is examined. Three trained analysts independently used HFACS to categorize observational human factors data collected at a teaching and nonteaching hospital system. Results revealed that the framework was substantially reliable overall (Study I: k = 0.635; Study II: k = 0.642). Reliability increased when only preconditions for unsafe acts were investigated (Study I: k =0.660; Study II: k = 0.726). Preconditions for unsafe acts were the most commonly identified issues, with HFACS categories being similarly populated across both hospitals. HFACS is a reliable tool for systematically categorizing observational data of human factors issues in the operating room. Findings have implications for the development of a HFACS tool for proactively collecting observational human factors data, eliminating the necessity ...
To date, the nature and role of ATC personnel in aviation accidents and incidents has yet to be f... more To date, the nature and role of ATC personnel in aviation accidents and incidents has yet to be fully examined. To remedy this situation, a comprehensive review of ATC-related accidents and incidents that occurred between January 1985 and December 1997 was conducted using records maintained by the NTSB. Results of the analysis revealed that ATC-related accidents and incidents are infrequent events. However, when these events do occur they are likely to involve local controllers interacting with multiple aircraft in the air during daylight VFR conditions. An in depth analysis of the narrative reports using the Human Factors Analysis and Classification System (HFACS) revealed that skill-based errors (attention failures and memory lapses) were the most common type of error committed by ATC personnel. Supervisory and organizational factors such as controller training, procedures, and oversight were cited in only a small fraction of the incident and accident reports. However, current accident and incident reporting systems were not designed with ATC errors in mind, making the analysis of latent factors, such as supervisory and organizational issues, extremely difficult. What is needed is a new error- analysis framework that will facilitate the gathering of information during ATC-related accident and incident investigations.
The International Journal of Aviation Psychology, Nov 13, 2009
ABSTRACT The Persian Gulf War provided a unique opportunity to collect data for examining aircrew... more ABSTRACT The Persian Gulf War provided a unique opportunity to collect data for examining aircrew work/rest cycles and operational tasking as they relate to aircrew readiness in a combat environment. For 4 consecutive weeks during Operations Desert Shield and Desert Storm, 18 A-6 (9 pilots, 9 bombardier/navigators) and 18 F-14 (10 pilots, 8 radar intercept officers) aircrew on board the USS America provided detailed daily activity data. Additional operational data and subjective reports of aircrew readiness (the amount of crew rest required before a combat mission could be flown) were obtained following each mission. Multiple-regression analysis indicated that flight duration, time of day that a flight occurred, number and order of flights in a day, and amount of sleep obtained 12 hr before flying aided in the prediction of aircrew combat readiness. These data provide valuable information for air wing commanders, senior mission planners, and air wing flight surgeons to consider when assessing aircrew readiness.
The objective of this panel was to discuss issues critical to the modern practice of science, wit... more The objective of this panel was to discuss issues critical to the modern practice of science, with a specific focus on how we train students to operate within a system that often slows scientific innovation. Chris Brill provided opening remarks to frame the discussion and introduce the panelists. Ben Lawson briefly summarized the most significant problems affecting modern science and how they limit discovery, stifle innovation, and reduce quality. The remaining panelists then provided brief opening remarks in response to Lawson's summary. Specifically, Frank Durso addressed how the current research and funding environments affects student training and career advice. Peter Hancock addressed how risk-averse sponsors and business models prohibit innovative research. Scott Shappell discussed how different Human Factors and Ergonomics (heretofore referenced as HF/E) career paths lead people to and from their roles as scientists. Specifically, he discussed how to prepare students for flexibility in the changing landscape of the business of science. The panel then turned to facilitated discussion with panelists and audience members. Specific themes included the business of science in relation to educational practices, the applied nature of HF/E training within the scientist/practitioner model, and implications of short-term funding schedules on education and research practices. The panel concluded by discussing how HF/E scientists/practitioners may be uniquely qualified to offer potential solutions to the above problems from educational and systemic perspectives.
: As a continuation of our previous work during Operation Desert Shield/Storm, we examined the ef... more : As a continuation of our previous work during Operation Desert Shield/Storm, we examined the effect a fleet exercise has on the work/rest patterns, fatigue, and cognitive performance of F/A-18 aviators. For 10 days during Fleet Exercise 1992, 25 pilots from VFA-81 and VFA-83 completed daily work/rest logs while performing their usual tasks. Subjective measure of fatigue, quality of rest, and sleep need were also collected. A subset of these F/A-18 pilots completed a brief battery of cognitive tasks as soon before flying as possible and again after the flight debrief. As a group, the pilots were adequately rested with little or no problem sleeping, and they operated on a typical work/rest schedule for deployed F/A-18 aviators. However, in some instances during which late night missions were flown, sleep onset was delayed, coupled with shorter sleep periods and additional sleep problems. Several work/ rest and flight related parameters were related to subjective measures of aircrew ...
Studies of offshore and maritime incidents (accidents and near-misses) show that 80% or more invo... more Studies of offshore and maritime incidents (accidents and near-misses) show that 80% or more involve human error. By investigating incidents, we can identify safety problems and take corrective actions to prevent future such events. While many offshore and maritime companies have incident investigation programs in place, most fall short in identifying and dealing with human errors. This paper discusses how to incorporate human factors into an incident investigation program. Topics include data collection and analysis and how to determine the types of safety interventions appropriate to safeguard against the identified risks. Examples are provided from three organizations that have established their own human factors investigation programs.
Proceedings of the Human Factors and Ergonomics Society Annual Meeting
ABSTRACT The objective of this panel was to discuss issues critical to the modern practice of sci... more ABSTRACT The objective of this panel was to discuss issues critical to the modern practice of science, with a specific focus on how we train students to operate within a system that often slows scientific innovation. Chris Brill provided opening remarks to frame the discussion and introduce the panelists. Ben Lawson briefly summarized the most significant problems affecting modern science and how they limit discovery, stifle innovation, and reduce quality. The remaining panelists then provided brief opening remarks in response to Lawson’s summary. Specifically, Frank Durso addressed how the current research and funding environments affects student training and career advice. Peter Hancock addressed how risk-averse sponsors and business models prohibit innovative research. Scott Shappell discussed how different Human Factors and Ergonomics (heretofore referenced as HF/E) career paths lead people to and from their roles as scientists. Specifically, he discussed how to prepare students for flexibility in the changing landscape of the business of science. The panel then turned to facilitated discussion with panelists and audience members. Specific themes included the business of science in relation to educational practices, the applied nature of HF/E training within the scientist/practitioner model, and implications of short-term funding schedules on education and research practices. The panel concluded by discussing how HF/E scientists/practitioners may be uniquely qualified to offer potential solutions to the above problems from educational and systemic perspectives.
This investigation explores flow disruptions observed during cardiothoracic surgery and how they ... more This investigation explores flow disruptions observed during cardiothoracic surgery and how they serve to disconnect anesthesia providers from their primary task. We can improve our understanding of this disengagement by exploring what we call the error space or the accumulated time required to resolve disruptions. Trained human factors students observed 10 cardiac procedures for disruptions impacting the anesthesia team and recorded the time required to resolve these events. Observations were classified using a human factors taxonomy. Of 301 disruptions observed, interruptions (e.g., those events related to alerts, distractions, searching activity, spilling/dropping, teaching moment, and task deviations) accounted for the greatest frequency of events (39.20%). The average amount of time needed for each disruption to be resolved was 48 seconds. Across 49.87 hours of observation, more than 4 hours were spent resolving disruptions to the anesthesia team's work flow. By defining a ...
: The fatigue and cognitive performance deficits associated with sleep loss and stress, like that... more : The fatigue and cognitive performance deficits associated with sleep loss and stress, like that experienced during sustained flight operations and nighttime flying, have motivated the search for effective nonpharmacological countermeasures. The behavioral effects of the potential countermeasure tyrosine, an amino-acid precursor to dopamine and norepinephrine, were examined during an episode of continuous nighttime work involving one night's sleep loss. Volunteers performed nine iterations of a battery of cognitive and subjective tasks for approximately 13 h, beginning at 1930 and ending at 0820 the following morning. Subjects remained awake throughout the day on which the experiment began and were awake for approximately 24 h by the end of testing. Six hours after the start of the experiment, one-half of the subjects received 150 mg/kg tyrosine in a split dose while the other half received a cornstarch placebo in a double-blind procedure. The tracking-task performance of tyros...
Over the last several decades, humans have played a progressively more important causal role in a... more Over the last several decades, humans have played a progressively more important causal role in aviation accidents as aircraft have become more. Consequently, a growing number of aviation organizations are tasking their safety personnel with developing safety programs to address the highly complex and often nebulous issue of human error. However, there is generally no “off-the-shelf” or standard approach for addressing human error in aviation. Indeed, recent years have seen a proliferation of human error frameworks and accident investigation schemes to the point where there now appears to be as many human error models as there are people interested in the topic. The purpose of the present document is to summarize research and technical articles that either directly present a specific human error or accident analysis system, or use error frameworks in analyzing human performance data within a specific context or task. The hope is that this review of the literature will provide practi...
American journal of medical quality : the official journal of the American College of Medical Quality, Jan 25, 2016
The reliability of the Human Factors Analysis and Classification System (HFACS) for classifying r... more The reliability of the Human Factors Analysis and Classification System (HFACS) for classifying retrospective observational human factors data in the cardiovascular operating room is examined. Three trained analysts independently used HFACS to categorize observational human factors data collected at a teaching and nonteaching hospital system. Results revealed that the framework was substantially reliable overall (Study I: k = 0.635; Study II: k = 0.642). Reliability increased when only preconditions for unsafe acts were investigated (Study I: k =0.660; Study II: k = 0.726). Preconditions for unsafe acts were the most commonly identified issues, with HFACS categories being similarly populated across both hospitals. HFACS is a reliable tool for systematically categorizing observational data of human factors issues in the operating room. Findings have implications for the development of a HFACS tool for proactively collecting observational human factors data, eliminating the necessity ...
To date, the nature and role of ATC personnel in aviation accidents and incidents has yet to be f... more To date, the nature and role of ATC personnel in aviation accidents and incidents has yet to be fully examined. To remedy this situation, a comprehensive review of ATC-related accidents and incidents that occurred between January 1985 and December 1997 was conducted using records maintained by the NTSB. Results of the analysis revealed that ATC-related accidents and incidents are infrequent events. However, when these events do occur they are likely to involve local controllers interacting with multiple aircraft in the air during daylight VFR conditions. An in depth analysis of the narrative reports using the Human Factors Analysis and Classification System (HFACS) revealed that skill-based errors (attention failures and memory lapses) were the most common type of error committed by ATC personnel. Supervisory and organizational factors such as controller training, procedures, and oversight were cited in only a small fraction of the incident and accident reports. However, current accident and incident reporting systems were not designed with ATC errors in mind, making the analysis of latent factors, such as supervisory and organizational issues, extremely difficult. What is needed is a new error- analysis framework that will facilitate the gathering of information during ATC-related accident and incident investigations.
The International Journal of Aviation Psychology, Nov 13, 2009
ABSTRACT The Persian Gulf War provided a unique opportunity to collect data for examining aircrew... more ABSTRACT The Persian Gulf War provided a unique opportunity to collect data for examining aircrew work/rest cycles and operational tasking as they relate to aircrew readiness in a combat environment. For 4 consecutive weeks during Operations Desert Shield and Desert Storm, 18 A-6 (9 pilots, 9 bombardier/navigators) and 18 F-14 (10 pilots, 8 radar intercept officers) aircrew on board the USS America provided detailed daily activity data. Additional operational data and subjective reports of aircrew readiness (the amount of crew rest required before a combat mission could be flown) were obtained following each mission. Multiple-regression analysis indicated that flight duration, time of day that a flight occurred, number and order of flights in a day, and amount of sleep obtained 12 hr before flying aided in the prediction of aircrew combat readiness. These data provide valuable information for air wing commanders, senior mission planners, and air wing flight surgeons to consider when assessing aircrew readiness.
The present study examined the role of human error and crew-resource management (CRM) failures in... more The present study examined the role of human error and crew-resource management (CRM) failures in U.S. Naval aviation mishaps. All tactical jet (TACAIR) and rotary wing Class A flight mishaps between fiscal years 1990-1996 were reviewed. Results indicated that over 75% of both TACAIR and rotary wing mishaps were attributable, at least in part, to some form of human error of which 70% were associated with aircrew human factors. Of these aircrew-related mishaps, approximately 56% involved at least one CRM failure. These percentages are very similar to those observed prior to the implementation of aircrew coordination training (ACT) in the fleet, suggesting that the initial benefits of the program have not persisted and that CRM failures continue to plague Naval aviation. Closer examination of these CRM-related mishaps suggest that the type of flight operations (preflight, routine, emergency) do play a role in the etiology of CRM failures. A larger percentage of CRM failures occurred during non-routine or extremis flight situations when TACAIR mishaps were considered. In contrast, a larger percentage of rotary wing CRM mishaps involved failures that occurred during routine flight operations. These findings illustrate the complex etiology of CRM failures within Naval aviation and support the need for ACT programs tailored to the unique problems faced by specific communities in the fleet.
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