Application of activity theory to analysis of human-related accidents: Method and case studies

This study proposes a new approach to human-related accident analysis based on activity theory. Most of the existing methods seem to be insufficient for comprehensive analysis of human activity-related contextual aspects of accidents when investigating the causes of human errors. Additionally, they identify causal factors and their interrelationships with a weak theoretical basis. We argue that activity theory offers useful concepts and insights to supplement existing methods. The proposed approach gives holistic contextual backgrounds for understanding and diagnosing human-related accidents. It also helps identify and organise causal factors in a consistent, systematic way. Two case studies in Korean nuclear power plants are presented to demonstrate the applicability of the proposed method. Human Factors Analysis and Classification System (HFACS) was also applied to the case studies. The results of using HFACS were then compared with those of using the proposed method. These case studies showed that the proposed approach could produce a meaningful set of human activity-related contextual factors, which cannot easily be obtained by using existing methods. It can be especially effective when analysts think it is important to diagnose accident situations with human activity-related contextual factors derived from a theoretically sound model and to identify accident-related contextual factors systematically.

[1]  Andrew Hale,et al.  Accident models and organisational factors in air transport: The need for multi-method models , 2011 .

[2]  Patrick Waterson,et al.  Systems thinking, the Swiss Cheese Model and accident analysis: a comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models. , 2014, Accident; analysis and prevention.

[3]  B. Nardi Context and consciousness: activity theory and human-computer interaction , 1995 .

[4]  James T. Reason,et al.  Achieving a safe culture : theory and practice , 1998 .

[5]  Sidney W A Dekker,et al.  Reconstructing human contributions to accidents: the new view on error and performance. , 2002, Journal of safety research.

[6]  Emmanuel Manatakis,et al.  Towards an evaluation of accident investigation methods in terms of their alignment with accident causation models , 2009 .

[7]  Helen Hasan,et al.  Demonstrations of the Activity Theory Framework for Research in Information Systems , 2007, Australas. J. Inf. Syst..

[8]  I. A. Herrera,et al.  Comparing a multi-linear (STEP) and systemic (FRAM) method for accident analysis , 2010, Reliab. Eng. Syst. Saf..

[9]  Jinkyun Park Scrutinizing inter-relations between performance influencing factors and the performance of human operators pertaining to the emergency tasks of nuclear power plant – An explanatory study , 2011 .

[10]  Maria Roussou,et al.  Exploring activity theory as a tool for evaluating interactivity and learning in virtual environments for children , 2008, Cognition, Technology & Work.

[11]  Erik Hollnagel,et al.  Cognitive reliability and error analysis method , 1998 .

[12]  I. Svedung,et al.  Graphic representation of accident scenarios: mapping system structure and the causation of accidents , 2002 .

[13]  Scott A. Shappell,et al.  A HUMAN ERROR APPROACH TO AVIATION ACCIDENT ANALYSIS , 2003 .

[14]  Sven Ove Hansson,et al.  Learning from accidents : what more do we need to know? , 2010 .

[15]  A. N. Leont’ev,et al.  Activity, consciousness, and personality , 1978 .

[16]  Nicolas Dechy,et al.  Accident Investigation: From Searching Direct Causes to Finding In-depth Causes – Problem of Analysis or/and of Analyst? , 2007 .

[17]  Snorre Sklet,et al.  Comparison of some selected methods for accident investigation. , 2004, Journal of hazardous materials.

[18]  D. L. Simms,et al.  Normal Accidents: Living with High-Risk Technologies , 1986 .

[19]  K. Weick Organizational Culture as a Source of High Reliability , 1987 .

[20]  Nicolas Dechy,et al.  Results and lessons learned from the ESReDA’s Accident Investigation Working Group: Introducing article to “Safety Science” special issue on “Industrial Events Investigation” , 2012 .

[21]  Kathryn Mearns,et al.  Designing and evaluating a human factors investigation tool (HFIT) for accident analysis , 2005 .

[22]  Gregory Z. Bedny,et al.  Safety and reliability analysis methods based on systemic-structural activity theory , 2013 .

[23]  Y. Engeström,et al.  Learning by expanding: An activity-theoretical approach to developmental research , 2014 .

[24]  Victor Kaptelinin,et al.  Acting with technology: Activity theory and interaction design , 2006, First Monday.

[25]  Scott A. Shappell,et al.  Human Error Perspectives in Aviation , 2001 .

[26]  Paul M. Salmon,et al.  Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP , 2012 .

[27]  Patrick Waterson,et al.  Systemic accident analysis: examining the gap between research and practice. , 2013, Accident; analysis and prevention.

[28]  Anders Jacobsson,et al.  A sequential method to identify underlying causes from industrial accidents reported to the MARS database , 2009 .

[29]  J. L. Coze What have we learned about learning from accidents? Post-disasters reflections , 2013 .

[30]  D. Woods,et al.  Behind Human Error , 2010 .

[31]  Don Harris,et al.  Pilot error and its relationship with higher organizational levels: HFACS analysis of 523 accidents. , 2006, Aviation, space, and environmental medicine.

[32]  Milos Ferjencik,et al.  An integrated approach to the analysis of incident causes , 2011 .

[33]  Jonas Lundberg,et al.  What you find is not always what you fix--how other aspects than causes of accidents decide recommendations for remedial actions. , 2010, Accident; analysis and prevention.

[34]  L. Vygotsky Mind in Society: The Development of Higher Psychological Processes: Harvard University Press , 1978 .

[35]  Nancy G. Leveson,et al.  A new accident model for engineering safer systems , 2004 .

[36]  Barry Kirwan,et al.  Development and application of a human error identification tool for air traffic control. , 2002, Applied ergonomics.

[37]  Anthony Morris,et al.  Activity Theory and the Analysis of Organizations , 1993 .

[38]  Guy H. Walker,et al.  Human Factors Methods and Accident Analysis: Practical Guidance and Case Study Applications , 2017 .

[39]  Xu Sun,et al.  Evaluating user experience of adaptive digital educational games with Activity Theory , 2012, Int. J. Hum. Comput. Stud..

[40]  Leena Norros,et al.  Core task analysis in accident investigation: analysis of maritime accidents in piloting situations , 2009, Cognition, Technology & Work.

[41]  Kenneth Pettersen,et al.  Explaining safe work practices in aviation line maintenance , 2008 .

[42]  Antonio Rizzo,et al.  Dependability Evaluation: Model and Method Based on Activity Theory , 2000, SAFECOMP.

[43]  Phil Turner,et al.  A web of contradictions , 2001, Interact. Comput..

[44]  Helene Hembrooke,et al.  Activity-Centered Design: An Ecological Approach to Designing Smart Tools and Usable Systems , 2004 .

[45]  Babette Fahlbruch,et al.  SOL – Safety through organizational learning: A method for event analysis , 2011 .

[46]  Zahid H. Qureshi,et al.  A review of accident modelling approaches for complex socio-technical systems , 2007 .

[47]  Erik Hollnagel,et al.  Barriers And Accident Prevention , 2004 .

[48]  Victor Kaptelinin,et al.  Methods & tools: The activity checklist: a tool for representing the “space” of context , 1999, INTR.

[49]  Dilani S.P. Gedera,et al.  Using Activity Theory to understand contradictions in an online university course facilitated by Moodle , 2013 .

[50]  Luiz Eduardo Galvão Martins,et al.  An approach to software requirements elicitation using precepts from activity theory , 1999, 14th IEEE International Conference on Automated Software Engineering.