In high-risk environments of seafaring, simulators constitute a widely used tool in preparing nauticalstudents for the challenges to be met in real-life working situations. While the technical developmentof ship bridge simulators continues at a breathtaking pace, little is known on how developments fulfiltheir intended safety critical purpose during actual simulator training exercises.In order to investigate this, a mixed-methods quasi-experimental field study (N =6) was conductedaiming at discerning the systemic causes behind committed human errors and to what extent thesecauses can be related to the technical layout of the simulator in general and a decision supportingdisplay in particular. The nautical students’ performance in terms of committed errors was analysedwhen the decision supporting display was either inactive or active during two different exercisebatches. Drawing upon eye tracking evaluation, interviews and simulator video recordings, systemiccauses leading to human errors were identified. Results indicate that all errors occur under the samekind of (stressful) interaction. Based on this design requirements aiming at promoting resilient crewbehaviour were proposed

This master’s thesis aims to analyze the possibilities of failure of human reliability on the example of an induction heater from company Roboterm spol. s.r.o. in Chotěboř. The objective of a thesis is a review of a literature of human reliability assessment. Based on the analysis of the operation and a literature review and choose the appropriate method to perform the actual assessment of the reliability of human error. Final object of the work is to propose measures to increase human reliability.

The present thesis focuses on the issue of assessing the reliability of the operator while operating CNC laser Adige LaserTube 8. The objective of this study was to perform a review of literature, which concerns the issue of assessing the reliability of the human factor. On the basis of the analysis was to choose the appropriate method in order to identify and assess risks in their workplace and then to assess the reliability of the operator. The practical part is to propose suitable measures to increase the reliability of the operator.

Within maintenance activities and industrial operations, human is subjected to different kind of stresses and situation that could result in mistakes and accidents. The human errors in maintenance and manufacturing are an unexplored latter such that a little focusis invested in this area. The report aims to widen up the understanding of the human error in maintenance and manufacturing area. Aviation and marine operations are the most sectors that are subjected to human errors according tothe literature. There aredifferent types of human error that have effect on quality and overall effectivity. Human reliability models are one method to quantify human errors and usually used for the identification of human errors and HEP calculation. The most common reliability measurement methods are HEART, THERP and SLIM which are used depending on application and industry. As a part of efforts to define differences between those reliability models, literature including different industries is used and itis found that expert judgement influences the success and accuracy of such methods. There are many causes for human errors depending on the application but, communication and procedures followed are the most contributing factors. There is always a probability of existence of human errors as the mistake done by workers are inevitable. Industry 4.0 can help in decreasing human errors through the introduction of operator 4.0 as well as other approaches like training and upgrading organizational standards.

Patient safety in healthcare has become a national objective. Healthcare organizations are striving to improve patient safety and have turned to high reliability organizations as those in which to model. One initiative taken on by healthcare is improving patient safety culture--shifting from one of a 'no harm, no foul' to a culture of learning that encourages the reporting of errors, even those in which patient harm does not occur. Lacking from the literature, however, is an understanding of how safety culture impacts outcomes. While there has been some research done in this area, and safety culture is argued to have an impact, the findings are not very diagnostic. In other words, safety culture has been studied such that an overall safety culture rating is provided and it is shown that a positive safety culture improves outcomes. However, this method does little to tell an organization what aspects of safety culture impact outcomes. Therefore, this dissertation sought to answer that question but analyzing safety culture from multiple dimensions. The results found as a part of this effort support previous work in other domains suggesting that hospital management and supervisor support does lead to improved perceptions of safety. The link between this support and outcomes, such as incidents and incident reporting, is more difficult to determine. The data suggests that employees are willing to report errors when they occur, but the low occurrence of such reportable events in healthcare precludes them from doing so. When a closer look was taken at the type of incidents that were reported, a positive relationship was found between support for patient safety and medication incidents. These results initially seem counterintuitive. To suggest a positive relationship between safety culture and medication incidents on the surface detracts from the research in other domains suggesting the opposite. It could be the case that an increase in incidents leads an organization to implement additional patient safety efforts, and therefore employees perceive a more positive safety culture. Clearly more research is needed in this area. Suggestions for future research and practical implications of this study are provided.

The diversity and dynamic nature of disaster management environments necessitate the use of convenient, yet reliable, tools for technology. While there have been many improvements in mitigating the effects of disasters, it is clearly evident by recent events, such as Hurricane Katrina that issues related to emergency response and management require considerable research and improvement to effectively respond to these situations. One of the links in a disaster management chain is the Emergency Operations Center (EOC). The EOC is a physical command center responsible for the overall strategic control of the disaster response and functions as an information and communication hub. The effectiveness and accuracy of the disaster response greatly depends on the quality and timeliness of inter-personnel communication within an EOC. The advent of handheld mobile communication devices have introduced new avenues of communication that been widely adopted by disaster management officials. The portability afforded by these devices allows users to exchange, manage and access vital information during critical situations. While their use and importance is gaining momentum, little is still known about the ergonomic and human reliability implications of human-handheld interaction, particularly in an Emergency Operations Center setting. The purpose of this effort is to establish basic human error probabilities (bHEP's) for handheld QWERTY data entry and to study the effects of various performance shaping factors, specifically, environmental conditions, communication load, and cognitive load. The factors selected are designed to simulate the conditions prevalent in an Emergency Operations Center. The objectives are accomplished through a three-factor between-subjects randomized full factorial experiment in which a bHEP value of 0.0296 is found. It is also determined that a combination of cognitive loading and environmental conditions has a statistically significant detrimental impact on the HEP.

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Modern complex safety-critical socio-technical systems (STSs) operate in an environment that requires high levels of human-machine interaction. Given the potential for catastrophic events , understanding human errors is a critical research area spanning disciplines such as management science, cognitive engineering, resilience engineering, and systems theory. However, a research gap remains when researching how errors impact system performance from a systemic perspective. This dissertation employs a systematic methodology and develops models that explore the relationship between errors and system performance, considering both macro-organizational and micro-worker perspectives. In Essay 1, the focus is on how firms respond to serious errors (catastrophic events), by exploring the oscillation behavior associated with the organizational learning and forgetting theory. The proposed simulation model contributes to the organizational science literature with a comprehensive approach that assesses the firm's response time to "serious" errors when the firm has a focus on safety with established safety thresholds. All of these considerations have subsequent impact on future performance. Essay 2 explores the relationship between safety-critical system's workers' workload, human error, and automation reliance for the Belgian railway traffic control center. Key findings include a positive relationship between traffic controller performance and workload, and an inverted U-shaped relationship with automation usage. This research offers new insights into the effects of cognitive workload and automation reliance in safety-critical STSs. Essay 3 introduces a calibrated System Dynamics model, informed by empirical data and existing theories on workload suboptimality. This essay contributes to the managerial understanding of workload management, particularly the feedback mechanism between operators' workload and human errors, which is driven by overload and underload thresholds. The model serves as a practical tool for managerial practitioners to estimate the likelihood of human errors based on workload distributions. Overall, this dissertation presents an interdisciplinary and pragmatic approach, blending theoretical and empirical methodologies. Its broad impacts extend across management science, cognitive engineering, and resilience engineering, contributing significantly to the understanding and management of safety-critical socio-technical systems. / Doctor of Philosophy / This dissertation is motivated by the increasing autonomy in infrastructure systems designed to enhance safety performance. Yet paradoxically, we continue to witness system failures leading to catastrophic disasters. High-profile incidents such as the Metro-North train derailment in New York City, the Boeing 737 MAX plane crashes, and the Challenger and Columbia space shuttle accidents highlight this contradiction. This research delves into safety-critical systems where the intricate collaboration between humans and machines is crucial, and where even minor human errors can lead to disastrous consequences. This dissertation is presented in three parts. In the first part I examine how firms react to serious errors. The study focuses on their learning processes following safety incidents and the potential for these lessons to be forgotten over time. I introduced a simulation model grounded in the organizational science literature, offering deeper insights into how companies respond to errors, including changes in safety focus, safety culture, and policy, and the impact of these factors on future company's performance. The second part shifts to a worker-centered perspective, exploring the relationship between workload, performance, and automation usage among traffic controllers. The findings indicate that while performance can improve with an increase in workload up to a certain threshold, excessive reliance on automation may lead to a decline in performance. This part of the study sheds light on how cognitive workload and technology usage influence operators in safety-critical roles. The final part of the dissertation presents another simulation model, this time focusing on how workload, and the resulting stress and boredom due to workload, influence the likelihood of errors. Utilizing real operational data from the Belgian railway transportation system, this model aids managers in understanding how to optimally balance workloads to minimize error risks. Overall, this dissertation takes an interdisciplinary and pragmatic approach, merging theoretical concepts with empirical data. Its extensive impact spans management science, cognitive engineering, and resilience engineering, significantly enhancing our comprehension and management of safety-critical socio-technical systems.

Fartygets beredskapsbåt är en viktig del i sjöräddningsarbetet för att till exempel rädda en nödställd person ur vattnet, men dessvärre sker olyckor i samband med användandet av denna. Syftet med detta arbete var att undersöka varför olyckor med beredskapsbåtar inträffar, genom att analysera haverirapporter om beredskapsbåtsolyckor ombord på fartyg med anknytning till Europa. 13 rapporter analyserades med hjälp av HFACS-MA-modellen. Metoden kategoriserar orsaker till olyckor och har givit en bild av vilka faktorer som varit de mest frekvent bidragande i de undersökta olycksfallen. Resultatet visade att fel och brister i konstruktionen (av till exempel dävert, krok och säkerhetsbrytare), otillräcklig eller obefintlig dokumentation inom organisationen (checklistor, manualer och instruktioner) och den fysiska arbetsplatsen (hur arbetsplatsen var utformad) var de främsta orsakerna till att olyckor med beredskapsbåtar inträffade. Av resultatet framgick även att kategorin förutsättningar, som till exempel yttre miljö och kommunikation, var en stor bidragande faktor. / The ship's rescue boat is an important part of search and rescue, for example to rescue a person in distress from the water, but unfortunately accidents happen in conjunction with the use of the boat. The purpose of this essay was to investigate why accidents with rescue boats occur by analyzing accident reports involving rescue boat accidents on ships with a connection to Europe. 13 reports were analyzed with the HFACS-MA model. The method categorizes the causes of accidents and has provided a picture of the factors that have been most contributory in the investigated accidents. The result showed that deficiencies in the design (for example davit, hook and breaker), insufficient or nonexistent documentation within the organization (checklists, manuals and instructions) and the function of the physical workplace, were the main reasons for why accidents involving rescue boats occur. The result also showed that the category preconditions, such as the external environment and communication, was a major contributing factor.

Approved for public release, distribution is unlimited / 235 Class A Navy and Marine (Naval) aviation mishaps involving aircrew error between FY 90 and FY 98 are analyzed for the possibility of being weather related. In addition to determining the overall role of weather, weather related mishaps are compared to aircraft category, mishap characteristic, the Naval Safety Center human factors (HFACS) taxonomy, and flight phase. In addition, weather related mishap trends have been analyzed. Results show 19% of mishaps involving aircrew error are weather related with helicopter category and controlled flight into terrain (CFIT) mishap characteristic having the largest percent of weather related mishaps for their respective groupings. Visibility related weather elements account for over half of all weather related mishaps, and nearly two-thirds of all weather related mishaps were judged to be preventable with a perfect weather forecast believed by aircrew. These and other findings are presented to develop intervention strategies for reducing the number of weather related flight mishaps (FMs) per year. / Lieutenant Commander, United States Navy