UBC Theses and Dissertations
The aetilology of error : cognitive profiling events within the mine workplace Sweeney, E. Douglas
Investigation of accidents, incidents and other unintended events in the workplace continues to evolve in the mining industry, as it has for other heavy industries. Traditional investigation approaches are grounded in causation – the determination of cause and effect relationships manifested by the evidentiary record. This approach, while intuitive and widely accepted, is not inclusive of the more distal elements of causality such as the influence of cognitive error and the perception of risk. This research examines the role of cognitive error in decisions that contribute to events; the nature of these errors and how they are indicative of organizational culture. The main objective of this research is to develop and evaluate a cognitive error tool that can be used in the analysis of events within the mining industry. The current taxonomies are few, and are not available in a robust and structured model easily applied by accident investigators. This research seeks to address this by offering a theory of event causality based upon decision errors (Decision Error); taxonomy of decision errors (Lost Error); and, a model for profiling cognitive error (Cognitive Profiling). Further, through cognitive profiling, it will be shown that there is a collective, or distributed, cognition that exists precursory to an event that heretofore has not been addressed by conventional causation modelling of events in the mine workplace. This research contributes to the field of human error analysis by proposing taxonomy based upon decision errors; and to the field of cognitive science by examining the role that risk perception has in cognition within the workplace. It provides a lexicon and a methodology that is exploratory in determining those events in the mine enterprise that are prone to escalation toward disaster; and by what errors in management such outcomes can be triggered. This research contributes to the field of accident theory and investigation by expanding on the notion of causation to include causality. It is shown that when events and their investigation are considered as systems with inputs, outputs, and processes; then there is another system at play – the human error system that is antecedent to events.
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