The development and application of a systemic human error identification and remediation methodology Public Deposited

http://ir.library.oregonstate.edu/concern/graduate_thesis_or_dissertations/d504rn51h

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  • This thesis describes a Systemic Vulnerability Identification and Remediation (SVIR) methodology that identifies human fallibilities and errors in complex technical processes, and recommends remediations for the errors, based on human factors principles and guidelines. The objectives of the research described in the thesis are the development of the methodology and evaluation of its effectiveness by applying it in an actual manufacturing process. The methodology improves upon conventional human error identification (HEI) frameworks by employing detailed IDEF0 modeling of the process, the use of a human fallibilities database, and integration of the technique through a series of analysis spreadsheets. Unlike many conventional HEI methodologies, SVIR utilizes published information that links human fallibilities to process characteristics in order to systematically identify possible human errors in a process. Results from the application of the methodology, including feedback from subject matter experts, suggested the methodology prospectively identifies likely errors that are potentially significant and recommends effective remediations. The thesis concludes with the summary of recommendations and contributions brought by this research. To improve the methodology, future researches using the SVIR methodology should consider to: 1. Re-evaluate the components of the SVIR process to decrease the amount of time SVIR requires. 2. Test for correct rejections of SVIR and invisibility of human errors. 3. Integrate components of the SVIR methodology to streamline the process. 4. Apply the SVIR methodology to another domain. The thesis has made the following contributions: 1. A HEI methodology that identifies human errors based on system characteristics and human fallibilities. 2. Application of the SVIR methodology to a manufacturing process and recommendations for improving the process. 3. Verification of methodologies of HFIRM and SVA.
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