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Human Factors
& System
By: Dessy Aliandrina
What did I learn from Socio-
Technical System
Disclaimer:
All images and figures presented subject to copyright and used only for
educational purposes
Prepared by @aliandrinade 2
How did we react to an event?
Prepared by @aliandrinade 3
• The accident occurred in 13 April,
2013
• The aircraft crashed into the sea
on approach
• The flight scheduled to land in
Ngurah Rai airport from Hussein
Sastranegara airport
• No fatalities, 46 injuries of 108
occupants
Prepared by @aliandrinade 4
(Source: Shutter stock)
We tend to seek for ‘something or someone’ to answer our thirst of curiosity about the event
Which is, many times, without proper knowledge about the event (e.g., sequences, context)
Prepared by @aliandrinade 5
Then, we construct our conclusion that might be faraway from the event without
conscious we have created other consequences (e.g., other victims)
Situation A Situation B
PROCESS
(Adapted from Jay Doblin in the 1987 Society of Typographic Arts Design Journal)
So, on designing a system
Prepared by @aliandrinade 6
Prepared by @aliandrinade 7
(Source: Vector Stock)
What will you do?
Ptolemaic Worldview (the
sun goes around the Earth)
Only the competent can
enter the system, so the
system should be
protected from unreliable
people
Copernican Worldview (the
Earth goes around the sun)
People at all levels in the
system should learn and
adapt continuously to
improve system performance
together
We do need to understand, at least, there are two scenarios
1
2
Prepared by @aliandrinade 8
Scenario 1 Scenario 2
Which one is more prone to err? And why?
(Source: Vector Stock)
We learn from the outcomeWe neglect the outcome
Prepared by @aliandrinade 9
Performance Levels
Source: Coined by Jens Rasmussen (1983)
and became the base model of Reason’s
error classifications
Though, there is no universal agreement about errors, here, I want to share one of perspectives about errors that
widely used either for individuals, organizations or even society.
Skill-based performance reflects
individual routine tasks or
familiar activity and can
become unconscious behavior.
In skilled-based performance,
possible reasons for any failure
or mistake tend to be failures of
attention or lapses of memory.
Rule-based performance
presents a mix of
consciousness and
unconsciousness behavior.
Performances can be correct
or in error if he meets with
good rules, bad rules or
even no rules.
Knowledge-based performance –
that is, conscious behavior– and
generally results from a shortage
or limitation of knowledge of how
to react in unfamiliar situations.
1. Skill-based performance 2. Rule-based performance 3. Knowledge-based performance
Prepared by @aliandrinade 10
Undeniable, to err is human because error or fallibility is a part of us. However,
we need to view errors are not, all the time, naturally bad.
Prepared by @aliandrinade 11
Instead of looking for ‘who’ and ‘what’ after an event, we need to look for ‘why’ and ‘how’
(Source: Vector Stock)
Prepared by @aliandrinade 12
Questions?
(Source: Vector Stock)

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#2 Human Factor and System_Dessy Aliandrina

  • 1. Human Factors & System By: Dessy Aliandrina What did I learn from Socio- Technical System
  • 2. Disclaimer: All images and figures presented subject to copyright and used only for educational purposes Prepared by @aliandrinade 2
  • 3. How did we react to an event? Prepared by @aliandrinade 3 • The accident occurred in 13 April, 2013 • The aircraft crashed into the sea on approach • The flight scheduled to land in Ngurah Rai airport from Hussein Sastranegara airport • No fatalities, 46 injuries of 108 occupants
  • 4. Prepared by @aliandrinade 4 (Source: Shutter stock) We tend to seek for ‘something or someone’ to answer our thirst of curiosity about the event Which is, many times, without proper knowledge about the event (e.g., sequences, context)
  • 5. Prepared by @aliandrinade 5 Then, we construct our conclusion that might be faraway from the event without conscious we have created other consequences (e.g., other victims)
  • 6. Situation A Situation B PROCESS (Adapted from Jay Doblin in the 1987 Society of Typographic Arts Design Journal) So, on designing a system Prepared by @aliandrinade 6
  • 7. Prepared by @aliandrinade 7 (Source: Vector Stock) What will you do? Ptolemaic Worldview (the sun goes around the Earth) Only the competent can enter the system, so the system should be protected from unreliable people Copernican Worldview (the Earth goes around the sun) People at all levels in the system should learn and adapt continuously to improve system performance together We do need to understand, at least, there are two scenarios 1 2
  • 8. Prepared by @aliandrinade 8 Scenario 1 Scenario 2 Which one is more prone to err? And why? (Source: Vector Stock) We learn from the outcomeWe neglect the outcome
  • 9. Prepared by @aliandrinade 9 Performance Levels Source: Coined by Jens Rasmussen (1983) and became the base model of Reason’s error classifications Though, there is no universal agreement about errors, here, I want to share one of perspectives about errors that widely used either for individuals, organizations or even society. Skill-based performance reflects individual routine tasks or familiar activity and can become unconscious behavior. In skilled-based performance, possible reasons for any failure or mistake tend to be failures of attention or lapses of memory. Rule-based performance presents a mix of consciousness and unconsciousness behavior. Performances can be correct or in error if he meets with good rules, bad rules or even no rules. Knowledge-based performance – that is, conscious behavior– and generally results from a shortage or limitation of knowledge of how to react in unfamiliar situations. 1. Skill-based performance 2. Rule-based performance 3. Knowledge-based performance
  • 10. Prepared by @aliandrinade 10 Undeniable, to err is human because error or fallibility is a part of us. However, we need to view errors are not, all the time, naturally bad.
  • 11. Prepared by @aliandrinade 11 Instead of looking for ‘who’ and ‘what’ after an event, we need to look for ‘why’ and ‘how’ (Source: Vector Stock)
  • 12. Prepared by @aliandrinade 12 Questions? (Source: Vector Stock)