Human Error Analysis: Cognitive Models and Decision Making

This assignment analyzes human error through the lens of cognitive models, focusing on skill-based, rule-based, and knowledge-based errors, as classified by Rasmussen's SKR scheme. It explores naturalistic decision-making (NDM) and its application in aviation, contrasting it with traditional decisio...Read More

Running Head: HUMAN ERROR 1
Human Error

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Answer 1.
Rasmussen (1983) developed a conceptual model, which can be applied to the design of the man-
machine interface, and has the potential to reduce the potential for accidents. The performance of
human brain can be characterized as goal-oriented or rule-controlled. Based on cognitive aspects
of human behavior, there are three associated errors, namely, skill-based, rule-based, and
knowledge-based error. This classification is commonly known as SKR (skills, rules, and
knowledge) scheme. This theory states that the human operator is at one of the three cognitive
level, which depends on the nature of the task and the associated level of experience.
The skill-based performance error is the error of execution, and this type of error is made by
extremely experienced people (Cacciabue, 2013). These people do not have to align different
pieces of information in the information interpretation and all the information processing is done
at the sub-conscious level. The reaction to the cues is automatic like walking or riding a bicycle.
The responses are based on pure stimulus-level, which are developed at neurological level, and
performance is governed at an automatic level. Rule-based performance error is advanced error,
which is faced when there is inability to identify the situation or circumstances. These errors are
due to both experience and training. The individuals who commit this type of error are familiar
with the task; however, do not have the amount of experience to accomplish it at subconscious
level. The cues are identifies and recognized, and based on the previous experience appropriate
actions are taken.

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The highest level of error is knowledge-based (Mital, Kilbom & Kumar, 2000). In these types of
error, people do not apply the skills and rules to the task or situation, but they apply the
previously learnt information or the previous experience to the new task (Kletz, 2008). The
individuals working at the knowledge-based level have challenges in grasping knowledge, or
limitation in applying the existing knowledge to the current situations.
Answer 2.
The naturalistic decision-making is based on the fundamental of bounded rationality. It states
that rational decision-making can only yield better decisions when there is time for taking a
decision, the goals and the issues are well defined for the organization or the decision-maker
(Podofillini et al. 2015).
It can be critiqued that most of the decisions and incidents in aviation are the result of poor
decision-making and judgmental strategies. The pilots are not taught to take decisions in highly
dynamic and risky environment. The traditional decision-making models are unable to explain
the decision taken by the pilots in complex accidents. It is because the pilots do not have ample
time to identify the root cause and evaluate different strategic choices.
The classical decision-making model states that the managers should always be logical and
rational while taking decisions. However, it is not possible in the dynamic environment of
aviation, as the pilots have to take quick decisions at a very small duration of time (Zsambok &
Klein, 2014). The laboratory decision-making model is focused on identifying the optimal
solution to the problem. It assists the managers in identifying the best decision for a specific

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problem. This model helps the decision-maker in problem structuring, determining the criteria
for identifying the solution and recognizing the best solution for a particular problem. However,
it is a time-consuming process; therefore, it cannot be applied to aviation.
The naturalistic decision-making is an intuitive strategy, which can be used by the pilots to
make operational decisions. The cockpit of airplane can be categorized as naturalistic
environment due to several characteristics such as experienced pilots, different team players,
dynamic operational conditions, dynamic goals, high risk, minor time-window, and ambiguous
or unavailable data. NDM strategies can be considered as an intuitive decision strategy used by
the pilots to make intuitive decisions. The strategies can assess the situation; evaluate the
decisions through mental evaluation. The intuitive and analytical decision-making strategies are
important in several situations. It includes situations in which there are limited goals, limited
time constraints, and correct set of information (You, Lu & Chen, 2015). Since the naturalistic
environment is dynamic, the decision maker should continuously reassess the situation and the
appropriateness of situational models. The pilot should evaluate the situation and take an
appropriate course of action to deal with the situation. However, the situational assessment and
awareness is crucial and time consuming. The situational assessment is important for good
decision-making and increasing the decision accuracy (Zsambok, & Klein, 2014).
The mental simulation is conducted before a decision action is taken. The decision maker
evaluates different course of action and selects the best approach. The simulation process
involves successive steps, which are required to be taken, potential outcomes of the process and
how these problems can be handled. However, if complete time is not available for the mental

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simulation, the decision maker will implement the action, which is based on the decision. The
decision will be taken based on the experience; however, subsequent changes would be made so
that satisfactory outcome can be produced.
Therefore, decisions taken from other decision models are unsuitable for aviation. It is due to the
reason that these methods work well only, when there is significant amount of time, information,
and money. However, such situations are rarely found in aviation. There are always conflicting
and incompatible goals in aviation and; therefore, a single, optimal decision cannot be made by
the pilots. Therefore, optimal decision is not available and is not necessary; however, good
decisions can equally serve the purpose. The result outcomes of such decisions are acceptable
with less amount of resources and time being invested. The naturalistic model yields such
decisions.
With the high level of risk and little amount of time, the pilots take the first workable decision
rather than comparing different decisions for optimality. There are very small chances that
changing the decision from good to optimal can increase the efficiency or safety of the
passengers. In different circumstances, the people choose different decision-making models,
which can yield the workable solution in least resources. The focus is not on the optimal
solution. However, in operational environment, the people should not invest personal resources
as the decision influence several different aspect of operations of a business organization.
In naturalistic situation, achieving an optimal solution is challenging and nearly impossible. An
optimal decision refers to a single, well-defined goal. However, in such cases, the situation
remains stable. In naturalistic environment, goals remain dynamic and competing. In the

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aviation, there are several dynamic goals such as safety, profit, company policy and customer
comfort. It is difficult to satisfy all of these criterions; therefore, the strategy cannot yield
analytical strategy (Simpson, 2001).
The naturalistic decision-making and the operator experience are interlinked. It is an important
relationship, as the naturalistic, intuitive strategies have to be taught to the learning pilots.
The recognition-primed decision making (RPD) is a model derived from naturalistic decision
making in which the alternative courses of action are derived by recognizing critical information
and knowledge. Different alternatives are examined; however, different options are not
compared with each other. The decision makers compare the current situation with their
experience and rules formed before. The decision is made by finding the similarities between
different situations; therefore, the decision-making model is named as recognition-primed
decision-making. There are three phases in this model, namely, situation recognition, serial
option evaluation, and mental simulation (Simpson, 2001).
Since the naturalistic environment is dynamic, the decision-maker has to examine the situation
and the changes in the environment rapidly. In the aviation, when the pilot understands the
situation, he can take an appropriate decision. The situational analysis is not appropriate model in
this situation as the awareness is crucial and it is a time consuming process. It is apt model for
decision-making and can increase the accuracy of the decisions (Salas & Martin, 2017).
The last stage before taking a decision is mental simulation in which the decision action is
implemented. The decision maker evaluates different courses of action by imagining the

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sequence of events, which will occur after the decision. The mental simulation includes the
successive steps of the decision, the outcomes of these steps, problems, which might be
encountered, and how these problems can be encountered. The decision maker can reject,
modifies, or implement the decision. If there is no ample time for decision-making, the focus is
on satisfactory decision rather than on optimal decision. In these cases, time is not available for
the mental simulation, therefore, the decision-maker takes a decision as per the experience,
which will be successful and provide a satisfactory outcome.
Answer 3.
The hierarchal task analysis (HTA) is a broad task analysis method, which analyzes the task
according to the hierarchy of the operations and plans designed according to the standard
notations of the chart. The hierarchal task analysis informs the analysts when different sub-tasks
should be executed so that the overall goal of the organization is met. In the task analysis, there
are three level of task analysis, goals, tasks, operations, or actions. There are several benefits of
hierarchical task analysis, because of which the method is popular. It is a cost-effective method,
as the hierarchal description is needed to be developed when it is needed to wherever it is needed
for the purpose of analysis (CCPS, 2010). The requirement of the training is negligible and it can
be easily implemented within the organization. The output of the analysis is beneficial for
different applications. The output provides detailed description of the task which provider great
insight to the user. It is a generic method and can be applied quickly.
This method is easy to learn and can be easily used by the people. It can serve as the basis of
several different assessments. This method is commonly used and is applicable on the cognitive

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analysis of the customers. The HTA is powerful method to analyze different types of physical
and mental activities and their application to different domains (Federal Aviation Administration,
2017).
There are also certain disadvantages of HTA such as the analysis has to develop skills to analyze
the tasks and the associated techniques. The focus of this analysis is on the descriptive analysis
rather than the analytical analysis. In case of complex decision-making tasks, HTA has to be
used in combination with other cognitive models (CCPS, 2010). However, the output cannot be
used for the design purpose. It does not meet the requirements of cognitive analysis and is not
efficient for large tasks. In this method, the data collection is very time-consuming. The
reliability of the method is also controversial as different analysts yield different results for the
same task.

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References
Cacciabue, P.C. (2013). Guide to Applying Human Factors Methods: Human Error and
Accident Management in Safety-Critical Systems. Springer Science & Business Media.
CCPS. (2010). Guidelines for Preventing Human Error in Process Safety. John Wiley & Sons.
Federal Aviation Administration. (2017). Task Analysis > Hierarchical Task Analysis (HTA).
Retrieved 14 January 2017 from https://www.hf.faa.gov/Workbenchtools/default.aspx?
rPage=Tooldetails&subCatId=28&toolID=106
Kletz, T. (2008). An Engineer's View of Human Error. IChemE.
Mital, A., Kilbom, A., & Kumar, S. (2000). Ergonomics Guidelines and Problem Solving.
Elsevier.
Podofillini, L., Sudret, B., Stojadinivic, B., Zio, E., & Kroger, W. (2015). Safety and Reliability
of Complex Engineered Systems: ESREL. CRC Press.
Salas, E., & Martin, L. (2017). Decision-Making Under Stress: Emerging Themes and
Applications. Routledge.
Simpson, P.A. (2001). Naturalistic Decision Making in Aviation Environments. DSTO
Aeronautical and Maritime Research Laboratory.

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You, J. X., Lu, C., & Chen, Y. Z. (2015). Evaluating health-care waste treatment technologies
using a hybrid multi-criteria decision making model. Renewable and Sustainable Energy
Reviews, 41, 932-942.
Zsambok, C.E., & Klein, G. (2014). Naturalistic Decision Making. Psychology Press. Liu, H. C.,