Errors from cognitive failures

The CADET technique can be applied both proactively and retrospectively. In its proactive mode, it can be used to identify potenrial cognitive errors, which can then be factored into CPQRA analyzes to help generate failure scenarios arising from mistakes as well as slips. As discussed in Chapter... 

Process transients and equipment failures may require workers to develop a new strategy to control the process. Detection, diagnosis, and fault-compensation are tasks in which workers may have little experience and the information needs may be different from those of familiar tasks. Again, methods of task and error analyses, particularly those concerned with human cognitive functions, may be useful in deciding what information should be displayed to help workers detect process transients, diagnose their causes and develop new strategies. 

The human factors literature is rich in task analysis techniques for situations and jobs requiring rule-based behavior (e.g., Kirwan and Ainsworth 1992). Some of these techniques can also be used for the analysis of cognitive tasks where weU-practiced work methods must be adapted to task variations and new circumstances. This can be achieved provided that task analysis goes beyond the recommended work methods and explores task variations that can cause failures of human performance. Hierarchical task analysis (Shepherd 1989), for instance, can be used to describe how operators set goals and plan their activities in terms of work methods, antecedent conditions, and expected feedback. When the analysis is expanded to cover not only normal situations but also task variations or changes in circumstances, it would be possible to record possible ways in which humans may fail and how they could recover from errors. Table 2 shows an analysis of a process control task where operators start up an oil refinery furnace. This is a safety-critical task because many safety systems are on manual mode, radio communications between control room and on-site personnel are intensive, side effects are not visible (e.g., accumulation of fuel in the fire box), and errors can lead to furnace explosions. 

Then in any case, the failure results from a coherent decision of the operating system (it is not a slip or a mistake , it is intentional at the collective level) we can consider that the failure results from a cognitive EOC at the level of the Operating System. That EOC is influenced by a context where an individual error could have happened. 

There is, however, a practical problem, namely that a terminology is not readily available. When we want to describe various types of individual and organisational failures, errors and malfunctions, a rich vocabulary is at our disposal. Starting from simple categories such as errors of omission and commission, we not only have multiple theories (violations, non-compliance, loss of situation awareness, cognitive errors, error-forcing conditions, etc.) but also a rich flora of terms within each theory. But when we want to describe what people actually do, there is little to start from. 

The first sigifificant work on errors (more specifically on failure) was done before the war (during the period from 1910 to 1940) and is classified under Gestalt theory or the theory of forms. This theory is considered to be the foundation of modem cognitive psychology. 

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