Sunday, January 01, 2006

Human Error in Transportation


Blogger CPRR Discussion Group said...

A related human factors study is Macintosh creator Jef Raskin's book, "The Humane Interface" reporting our work on how the computers can be made much easier to learn and use. With the increased use of computers to control complex equipment, for example in transportation, errors with tragic consequences will inevitably result if the results of human factors research into the capabilities and limitations that people bring to tasks that they undertake are ignored when designing equipment.

For example, people can pay attention to only one thing at a time. Also, designing a system with modes will inevitably result in human errors — it is no historical accident that the only mode on a typewriter keyboard, the shift lock key, gave rise to the written way of expressing swearing: #(%*$@! (the result of attempting to type a number while in the wrong mode).

As your study discusses, regulation can play an important role in causing accidents. The best example is the nuclear reactor explosion at Chernobyl, where the Soviet government's dysfunctional attempt to over-regulate everything resulted in numerous safety rules being ignored. Nobody can keep in mind thousands of senseless rules that must be routinely ignored in order to get through the day, and this mindset due to regulatory overload prevents critcally important safety rules from being remembered and observed.

Even better would be to make fundamental the equipment and system design principle that all possible actions must have reasonable and safe results – thereby designing out both error messages and damaging results. (Attempting to follow this principle where it is not thought possible will often lead to unanticipated radical improvements and simplifications.)

1/01/2006 1:55 PM  
Blogger CPRR Discussion Group said...


Thank you for your informed feedback. ...

Yes, government can certainly play a role in causation of errors, near misses, and accidents. In various FRA RSACs that I have been attending since 1998, I am especially interested in the FRA's statements and actions at the meetings and its supporting documents and, then, in FRA rulemaking and field practices. I feel FRA is a bit wary of me.

As you might know, we (including CPR) are now engaged in an FRA RSAC working group concerning federalization of particular operating rules (hence, criminalization of a violation). I do not at all like the idea (or future FRA practice) of making criminals out of either rank-and-file RRers or RR officers. (As I mentioned, I have had close CPR friends on the GM, div. super, and TM levels.) I don't know of any other academic for whom CPR had a rail painting specially done. I look at it now across from my desk.

I feel given the many cooperative, labor-management, safety programs either now or recently in progress, the industry has this model of the road to take to increase RR operating safety. Criminalization is not the scientific human factors road. CPR's safety-related protocol manual and its On-Board Crew Audit are among such positive steps too take for enhancing safety and to share with other carriers.


1/02/2006 2:12 PM  
Anonymous Anonymous said...

Such draconian regulation bespeaks desperation over failed ideas. (As in dictatorship defined as "a form of government under which everything not prohibited is compulsory.")

In contrast, according to their former (among other positions) railroad Minister, New Zealand rolled back government, for example, reducing their Department of Transportation from 5,600 employees to 53.

1/02/2006 2:19 PM  

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