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23-Ind-B5 Ergonomics · December 2018

Question 3 of 4: Reason's Model of Human Error — Hauler Machine Operation

Nivaar worked solution (AI-drafted; not reviewed by a licensed engineer)

Notes on this paper

National Exams — Dec. 2018 — 17-Ind-B5 Ergonomics. Three-hour, open-book exam (any non-communicating calculator permitted); NIOSH lifting tables (Appendix 1) and a manual-materials-handling assist-device table (Appendix 2) are supplied on the exam's own pages. The paper's instructions state a total of four questions: Part A (Questions 1–2) is mandatory, Part B asks the candidate to choose one of Questions 3 or 4. All four questions are solved below.

Reference texts: Sanders & McCormick, Human Factors in Engineering and Design (7th ed.) — environmental ergonomics, human-factors analysis methods, error taxonomy (Reason's model), and controls/displays population-stereotype/spatial-compatibility principles (incl. the classic Chapanis & Lindenbaum stove-burner control-panel study); Waters, Putz-Anderson & Garg, NIOSH Applications Manual for the Revised NIOSH Lifting Equation (1994) — the RWL/LI formula and multiplier tables reproduced on the exam's own Appendix 1; NIOSH, Elements of Ergonomics Programs (1997) and CSA Z1004 (Canada) — workplace musculoskeletal-disorder (MSD) prevention programs; CSA Z1002 — hazard identification, elimination and risk assessment.

Question 3: Reason's Model of Human Error — Hauler Machine Operation (20 marks: a–10, b–10)

Question text not reproduced: the examination questions are © Engineers and Geoscientists BC. Open the official past paper (linked at the top of this page) to read the question, then follow the worked solution below.

Part (a) — Classification of Each Error

Reason's model (Fig. 2) traces an action from a stimulus through interpretation/situation assessment and plan/intention of action (drawing on memory) to action execution, with a feedback loop back to interpretation. Mistakes are planning errors – the wrong intention is formed at interpretation or planning (the intention is carried out correctly, but it was the wrong intention); slips are execution errors – the intention was correct but the action itself goes wrong; lapses and mode errors are memory failures – a step is omitted or the wrong stored routine is triggered. The model is also commonly extended with a fourth category, violations – a deliberate deviation from a known safe procedure, which is not a processing failure at all and therefore does not map onto any box in Fig. 2.

#ErrorTypeJustification
1Hauler not returned for service on scheduleLapseAn administrative/memory failure – the scheduling step is forgotten or not triggered at the right time, not a wrong decision or a botched action.
2Setting off with parking brake onLapse (omission)The release-brake step of a well-learned start-up sequence is skipped from memory; the intention (to drive off) and the executed action (drive off) are both otherwise correct.
3Driving while sitting on the rear bumperViolationA deliberate departure from a known safe operating procedure (operate from the seat) – not a processing failure, so it falls outside Reason's error boxes entirely.
4Misreading of displaysSlipA perceptual/execution error at the interpretation stage of an otherwise correct plan – the operator intends to read the display correctly but the perceptual act goes wrong (a description-type slip).
5Leaning out of cab while travellingViolationA deliberate unsafe act (usually for a better sightline), performed knowingly rather than by mistake or memory failure.
6Insufficient warning while backing upMistake (rule-based)Reflects a habitually wrong or incomplete procedure for backing up (an incorrect “if-then” rule being applied), rather than a one-off slip – the plan itself is deficient.
7Instability prevents effective fire-extinguisher useNot a human error – design/engineering deficiencyThis is a property of the machine/mount design, not a human action at all, so it does not fit any box of Reason's operator-error model; it needs an engineering fix, not a human-factors intervention aimed at the operator.
8Incorrect operation of machine controlsMistake (rule-based) or slipIf the operator consistently uses the wrong control sequence, it is a rule-based mistake (wrong learned procedure); if it is an occasional wrong-button action despite correct intent, it is a slip – distinguishing the two requires observing whether the error repeats systematically or occurs sporadically.
9Tires not maintained per accepted practiceLapse / organizationalLike item 1, a scheduled-maintenance step omitted from an administrative memory system, rather than an in-cab operating error.
10Operating too fast when fully loadedViolationA known speed limit for the loaded condition is knowingly exceeded – a deliberate risk-taking act, not a slip, lapse or mistaken plan.

Part (b) — Human Factors Interventions per Error Type

Interventions are matched to the error mechanism identified in Part (a), since a single blanket fix (e.g. “more training”) does not correct every category:

[Figure not reproduced: Fig. 3 — Reason's model of human error (1991), redrawn per the source Figure 2: mistakes originate at interpretation/planning, slips at action execution, and lapses/mode errors from memory. See the official exam paper.]