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Designing effective complex systems in Aviation and Healthcare

Designing effective complex systems in Aviation and Healthcare. APCHI ERGOFUTURE-PEI-IAFI 2014 Bali, October 22–25, 2014. Paola Amaldi & Sara Khalil School of Life and Medical Sciences University of Hertfordshire. Design of human automation interaction.

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Designing effective complex systems in Aviation and Healthcare

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  1. Designing effective complex systems in Aviation and Healthcare APCHI ERGOFUTURE-PEI-IAFI 2014 Bali, October 22–25, 2014 Paola Amaldi & Sara Khalil School of Life and Medical Sciences University of Hertfordshire

  2. Design of human automation interaction • Design of alarm/alert devices for use in socio technical and safety critical domains (e.g., aviation and healthcare).

  3. Cognitive System Engineering (CSE) & Computer Supported Cooperative Work (CSCW) Safety critical socio-technical systems CSCW CSE Convergence on human automation cooperation issues Will benefit Human Automation Interaction (Alarm) design

  4. Alarms in Nuclear Power Plants • "I would have liked to have thrown away the alarm panel. It wasn't giving us any useful information.” • Comment by one operator at the Three Mile Island nuclear power plant to the official inquiry following the TMI accident (Kemeny 1979).

  5. Nuclear Power Plant

  6. Alarm in Aerospace • Alarm could be triggered by trivial problems that could be ignored altogether. Or it could be triggered by problems that called for an immediate abort [of the lunar landing]. How to decide which was which? • […] because even within a single […] the alarm might signify many different things.

  7. Alarms in Healthcare • "I know exactly what it [an alarm] is--it’s because the patient has been, hasn’t taken enough breaths or--I’m not sure exactly why.” • Physician explaining one alarm on a computerized operating room device that commonly occurred at a particular stage of surgery (Cook et al. 1991).

  8. Alarm in Air Traffic Control • Minimum Safe Altitude Warning system is designed to aid air traffic controllers to advise pilots when their aircraft appears to be at risk of colliding into terrain or obstacles.

  9. Minimum Safe Altitude Warning (Rozzi, 2008) • “We saw the MSAW just as a minor technical system, something like, something that controllers would have barely noticed. We did not imagine the mess lying ahead with all the nuisance alerts and the need to parameterize the system“(Supervisor Interview). • MSAW for ATC to advise pilots when their aircraft appears to be at risk of colliding into terrain or obstacles

  10. The ‘alarm problem’Woods 1995 • Nuisance alarms can be ambiguous • underspecified alarm messages, • alarm inflation • alarms might distract and disrupt other tasks • Alarms intervening where there is a need to act to prioritize information processing tasks

  11. Cognitive System Engineering (CSE) & Computer Supported Cooperative Work (CSCW) Safety critical socio-technical systems CSCW CSE Convergence on human automation cooperation issues Will benefit Human Automation Interaction (Alarm) design

  12. Cognitive System Engineering (CSE) FUNCTION ALLOCATION MABA-MABA Machines are best at Men Are Best At From Fitts 1951; Hollnagel, 1999

  13. CO ACTIVE MATRIX Levels of automation (Sheridan & Parasuraman ‘02) & human automation interaction matrix (adapted from Johnson et al. ‘10)

  14. Cognitive System Engineering and alarm devices • Reliability (rate of False Alarm, nuisance alarm) and ‘cry wolf’ effect • Wickens, Rice et al (09) : ATCOs not affected by FA rate in their ability to discriminate alarms linked to LoS • Lees, Lee (07) distinguished False/Un-necessary alarms according to ✔Clear logic; ✔Understandable; ✔Useful • Woods (95) Alarms should be informative at a pre-attentional level.

  15. CSCW & Articulation Work • Interdependence of actors whose individual actions affect their own and others’ fields of work • Individual activities have to be articulatedin order to reconcile incompatible conceptualizations, conflicting/competing goals • Artifactually imprinted protocols

  16. CSCW Statements: a coordination mechanism is an organisational construct consisting of an artifactually imprinted protocol capable of stipulating and mediating the articulation of cooperative work so as to reduce the complexity of the articulation work. (Shmidt & Simone, 1996)

  17. Daily Mail Newspaper 2014 • Having one standard hospital 'patient score card' could save 6,000 lives every year • Currently more than 100 different types of charts to monitor patients in the UK • One standard chart would help nurses and doctors when they move hospitals

  18. E_Flight strip (en route)

  19. E_flight strips (airports)

  20. Computationally coordination mechanisms • CSCW Proposition. The allocation of functionality reflects the extent to which it is feasible to incorporate conventions and routines of the social context into a computational protocol. No computational coordination mechanism will be able to handle all aspects of articulation work in any work domains. (Schmidt & Simone, 1996)

  21. ACAS generates two advisories Traffic Advisories (TA) warns of a potential threat Resolution Advisory (RA) issues an action to avoid collision

  22. ACAS lacks pilot intent knowledge 1000 feet Level Off Closure rate

  23. TCAS & Pilots behavior • 90% Pilots’ compliance with TCAS Resolution Advisories (RAs) • 75% a/c separation was above threshold • 47% trajectory deviation >300 feet • Non nominal use found in • Regulating speed during final approach; • Assist in navigation APCHI ERGOFUTURE 2014, Bali, October 22 -25 P. Amaldi & S. Khalil

  24. Ubërlingen mid air collision & Traffic Information ATC: “Climb” ATC: “Descend” TCAS

  25. Pilots’ appraisal of the RA APCHI ERGOFUTURE 2014, Bali, October 22 -25 P. Amaldi & S. Khalil

  26. ATC judgement of RA’s in relation to workload APCHI ERGOFUTURE 2014, Bali, October 22 -25 P. Amaldi & S. Khalil

  27. ACAS-induced articulation work Eurocontrol ACAS Bulletin May 2012

  28. Interdependence matrix & coactive design , ACAS scores quite high in Self sufficiency, • completely autonomous (from ‘manual input”) • detecting traffic problems • issuing resolution. • Quite low in self directedness: • it issues advisories but dependent on human input for the execution of the maneuver. • Low in interdependence • it provides assistance as revealed by the ‘useful” and “necessary” appraisal • some feedback But it scored quite low in terms of its: • predictability • detectability • transparency • knowledge of intent of the other agents

  29. Articulation work • Alarm devices generate articulation work • Information output of the alarm has to be made compatible with the rest of the activities • Computational coordination mechanisims should be identified togeher with other funcionalities early in the design life cycle

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