Applying a Dynamic Model of Situated Cognition to the Investigation of Mishaps

Abstract

Complex systems will, inevitably, experience failures. The cause of these failures or mishaps may be labeled 'operator error,' but often they are actually caused by the confluence of technological, situational, individual, and organizational factors. Several models and theories of human error have been proposed over the years and are reviewed in this paper. The authors propose another model, the Dynamic Model of Situated Cognition (DMSC), to explain how complex systems fail. Miller and Shattuck (2004) developed the DMSC in an effort to link technological aspects of a system to the perceptual and cognitive aspects of that system. They illustrated the model by applying it to the USS Stark incident and to a military command and control simulation (Shattuck and Miller, 2004). The model also appears to have utility as a retrospective explanatory tool to identify when and where things went wrong. In this paper, the authors describe the DMSC as it relates to the analysis of error in complex systems and apply it to the February 2001 mishap in which the U.S. Navy submarine USS Greeneville collided with the Japanese motor vessel Ehime Maru off the coast of Oahu, Hawaii.

Get full access to this article

View all access options for this article.

References

Dekker

(2002). The field guide to human error investigations. Burlington, VT: Ashgate.

Dorner

(1989). The logic of failure: Recognizing and avoiding error in complex situations. Cambridge, MA: Perseus Books.

Executive Summary of USS Greenville collision, retrieved 04/14/2005 from http://www.cpf.navy.mil/greenevillehtml http://www.cpf.navy.mil/pages/legal/foia/Executive_Summary3.pdf.

Levinson

Edwards

R.L.

(1997). Missile inbound: The attack on the Stark in the Persian Gulf. Annapolis, MD: Naval Institute Press.

Miller

N.L.

Shattuck

L.G.

(2004). A process model of situated cognition in military command and control. In Proceedings of the 2004 Command and Control Research and Technology Symposium, San Diego, CA.

Moray

(1994). Error reduction as a system problem. In Bogner

M.S.

(Ed.), Human error in medicine (pp. 67–91). Hillsdale, NJ: Lawrence Erlbaum Associates.

Moray

(2000). Culture, politics, and ergonomics. Ergonomics, 43, 858–868.

Reason

(1990). Human error. Cambridge: University Press.

Reason

(1997). Managing the risks of organizational accidents. Burlington, VT: Ashgate.

10.

Senders

J.W.

Moray

N.P.

(1991). Human error: Cause, prediction, and reduction. Hillsdale, NJ: Lawrence Erlbaum Associates.

11.

Shattuck

L.G.

Miller

N.L.

(2004). A process tracing approach to the investigation of situated cognition. In Proceedings of the Human Factors and Ergonomics Society 48th Annual Meeting (pp. 658–662). Santa Monica, CA: Human Factors and Ergonomics Society.

12.

Snook

(2000). Friendly fire: The accidental shootdown of U.S. Blackhawks over northern Iraq. Princeton, NJ: Princeton University Press.

13.

Strauch

(2002). Investigating human error: Incidents, accidents, and complex systems. Burlington, VT: Ashgate.

14.

Wiegmann

D.A.

Shappell

S.A.

(2003). A Human Error Approach to Aviation Accident Analysis: The Human Factors Analysis and Classification System. Burlington, VT: Ashgate.

15.

Woods

D.D.

Johannesen

L.J.

Cook

R.I.

Sarter

N.B.

(1994). Behind human error: Cognitive systems, computers, and hindsight. Wright-Patterson Air Force Base, OH: Crew Systems Ergonomics Information Analysis Center.