INTERVENTION STRATEGIES FOR THE MANAGEMENT OF HUMAN ERROR

Wiener, Earl L. · 1993 · NASA Technical Reports Server (NASA)

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Summary

This 1993 NASA contractor report by Earl L. Wiener addresses the management of human error in complex human-machine systems, with a primary focus on modern aviation cockpits. The research is motivated by the persistent vulnerability of highly sophisticated systems to crew errors, which remain a leading cause of accidents in aviation, shipping, nuclear power, and other high-risk domains. Wiener distinguishes "error management" from simple error prevention, defining it as a broader strategy that includes preventing errors, detecting them when they occur, and trapping them to prevent adverse system outcomes. The study aims to match specific error demands with appropriate intervention resources, providing a framework for designing and evaluating these strategies. The paper employs a review and analytical approach, synthesizing insights from cognitive psychology, systems engineering, and aviation safety data. It categorizes interventions into two models: those targeting specific, well-defined errors (e.g., wrong runway landings) and those addressing vague, systemic sources of error (e.g., complacency or fatigue). The analysis covers both traditional technologies—such as hardware design, procedures, checklists, communication protocols, and training—and advanced technologies, including fault-tolerant designs and "error-evident" displays. The author introduces the concept of "lines of defense," viewing safety systems as cascaded filters that can stop or mitigate errors. The report also incorporates case studies, such as the Northwest Flight 255 accident, and analyzes the impact of cockpit automation, noting that while automation may eliminate small manual errors, it can invite larger, more severe blunders if not properly managed. Key findings indicate that human error can be effectively managed through a combination of traditional and advanced interventions. The report highlights that traditional methods, such as standardized procedures and checklists, remain critical guardians of safety despite the advent of advanced technology. However, the author notes that accident rates have plateaued, suggesting that current methods may be insufficient for future traffic growth. The study identifies specific intervention techniques, including improving feedback loops, employing "intent-driven" systems that share goals between humans and machines, and designing displays that make erroneous inputs obvious. The paper also warns that interventions can have trade-offs; for example, warning systems may generate false alarms, and increased communication requirements can lead to frequency congestion. Fifteen guidelines for the design and implementation of intervention strategies are provided to help practitioners evaluate the feasibility, cost, and applicability of proposed solutions. The significance of this work lies in its comprehensive framework for managing human error in automated systems. By shifting the focus from mere prevention to active management and trapping of errors, the report offers a pragmatic approach to enhancing safety in high-stakes environments. It underscores the need for continuous improvement in intervention strategies to address the changing nature of errors introduced by automation. The guidelines provided serve as a template for designers and policymakers to ensure that new technologies and procedures effectively mitigate risk without introducing new vulnerabilities. Ultimately, the report argues that a multi-layered defense strategy, combining human factors engineering with advanced computer techniques, is essential for maintaining safety as systems become increasingly complex and automated.

Key finding

Effective management of human error requires a combination of traditional interventions like training and procedures alongside advanced technologies such as error-evident displays, guided by specific design principles.

Methodology

review

Provenance

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Topics

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• human error taxonomy