Learning from Automation Surprises and "Going Sour" Accidents: Progress on Human-Centered Automation

Advances in technology and new levels of automation on commercial jet transports has had many effects. There have been positive effects from both an economic and a safety point of view. The technology changes on the flight deck also have had reverberating effects on many other aspects of the aviation system and different aspects of human performance. Operational experience, research investigations, incidents, and occasionally accidents have shown that new and sometimes surprising problems have arisen as well. What are these problems with cockpit automation, and what should we learn from them? Do they represent over-automation or human error? Or instead perhaps there is a third possibility - they represent coordination breakdowns between operators and the automation? Are the problems just a series of small independent glitches revealed by specific accidents or near misses? Do these glitches represent a few small areas where there are cracks to be patched in what is otherwise a record of outstanding designs and systems? Or do these problems provide us with evidence about deeper factors that we need to address if we are to maintain and improve aviation safety in a changing world? How do the reverberations of technology change on the flight deck provide insight into generic issues about developing human-centered technologies and systems (Winograd and Woods, 1997)? Based on a series of investigations of pilot interaction with cockpit automation (Sarter and Woods, 1992; 1994; 1995; 1997a, 1997 b), supplemented by surveys, operational experience and incident data from other studies (e.g., Degani et al., 1995; Eldredge et al., 1991; Tenney et al., 1995; Wiener, 1989), we too have found that the problems that surround crew interaction with automation are more than a series of individual glitches. These difficulties are symptoms that indicate deeper patterns and phenomena concerning human-machine cooperation and paths towards disaster. In addition, we find the same kinds of patterns behind results from studies of physician interaction with computer-based systems in critical care medicine (e.g., Moll van Charante et al., 1993; Obradovich and Woods, 1996; Cook and Woods, 1996). Many of the results and implications of this kind of research are synthesized and discussed in two comprehensive volumes, Billings (1996) and Woods et al. (1994). This paper summarizes the pattern that has emerged from our research, related research, incident reports, and accident investigations. It uses this new understanding of why problems arise to point to new investment strategies that can help us deal with the perceived "human error" problem, make automation more of a team player, and maintain and improve safety

A human-factors approach to capture medical device safety, performance and usability

Advances in medical technology including computer aided and robotic surgery, digital health and increased use of portable devices have improved patient care in both hospital and home environments. These advancements have brought an increased level of complexity in patient care with new challenges to both patients and clinicians. The available performance data on medical devices (MD) is scarce and of variable quality despite work from regulatory bodies, with multiple associated challenges and lack of effective systems in place for its collection. This research used human factor methods to address i) the current state of safety and performance data availability for MDs and ii) methods of capturing safety and usability data in hospital and home environments by using human factor methods. Part A of this thesis concentrated on hospital based devices whilst Part B addressed home use MDs. End user experiences were utilised throughout to gain an understanding of the current system including its challenges and reasons leading to lack of data. Patients, clinicians, manufacturers, human factor specialists and MHRA were involved at all stages of this research. The studies led to the developments of the pathway map to reporting and information transfer in operating theatres and furthermore the development and initial evaluation of the MD-PRS concept (Medical Device Performance Reporting System) as a single dedicated method of reporting all MD malfunctions/ failures. The My-VID usability tool (My Voice in Design) was developed and evaluated as a method for collecting usability data directly from patients on home use MDs. In conclusion, this thesis used human factor methods to better understand the current system of data collection, available data sources on MDs and challenges faced prior to developing methods for improvement, based on end user experiences . Finally, methods of applying this research to clinical practice were addressed in the final chapter.Open Acces

Reactions to insanity : a study of stigma, discrimination and labelling in relation to present and former psychiatric patients

The thesis is organised around an empirical investigation of the relationship between residents of a Hertfordshire village and people who are, or who have been, patients at a nearby psychiatric hospital, some of whom regularly venture into the village to use local facilities. The research employs the method of participant observation and draws upon the discourse analytic approach of Potter and Wetherell, together with the rhetorical perspective of Michael Billig. In particular, the research focuses upon the discursive practices of local people, practices which function to sustain, amplify or minimise difference between themselves and others who are patients. The critical theory of Jürgen Habermas is drawn upon to complement and extend the discourse analysis approach, which receives critical evaluation. In addition, the time-geography of Alan Pred is employed as an heuristic for the representation of journeys of patients in the village. The historical dimension of the relationship between village and hospital is addressed by drawing upon Parish Council minutes and local newspaper reports. The thesis contains a conceptual investigation of public anxieties concerning mental disorder, an overview and discussion of the contemporary relevance of the labelling perspective, and a review of relevant literature. In addition it provides an exploration of methodological and textual issue

Reactions to insanity : a study of stigma, discrimination and labelling in relation to present and former psychiatric patients

The thesis is organised around an empirical investigation of the relationship between residents of a Hertfordshire village and people who are, or who have been, patients at a nearby psychiatric hospital, some of whom regularly venture into the village to use local facilities. The research employs the method of participant observation and draws upon the discourse analytic approach of Potter and Wetherell, together with the rhetorical perspective of Michael Billig. In particular, the research focuses upon the discursive practices of local people, practices which function to sustain, amplify or minimise difference between themselves and others who are patients. The critical theory of Jürgen Habermas is drawn upon to complement and extend the discourse analysis approach, which receives critical evaluation. In addition, the time-geography of Alan Pred is employed as an heuristic for the representation of journeys of patients in the village. The historical dimension of the relationship between village and hospital is addressed by drawing upon Parish Council minutes and local newspaper reports. The thesis contains a conceptual investigation of public anxieties concerning mental disorder, an overview and discussion of the contemporary relevance of the labelling perspective, and a review of relevant literature. In addition it provides an exploration of methodological and textual issue

Mustang Daily, February 17, 1993

Student newspaper of California Polytechnic State University, San Luis Obispo, CA.https://digitalcommons.calpoly.edu/studentnewspaper/5524/thumbnail.jp