Errors from cognitive failures causes

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. 

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