My notes on Dr. Richard Cook's lectures on the study of cognitive work.
For more information about Richard Cook, see:
- The Career, Accomplishments, and Impact of Richard I. Cook: A Life in Many Acts
- Richard Cook's Wikipedia page
| # | Title |
|---|---|
| 1 | It all started at TMI, 1979 |
| 2 | Understanding cognitive demands & goal conflicts; Dryden Air Ontario Crash, 1989 |
| 3 | Bootstrapping, Artifacts, and Tokaimura, 1999 |
| 4 | Process tracing Texas City BP explosion 2005 |
| 5 | (missing) |
| 6 | Stark, Vincennes, RPD, and NDM |
| 7 | Jeffrey Braithwaite Looks at Safety |
| 8 | Review |
The lectures reference the following accidents:
- Three Mile Island accident, March 1979
- Dryden Air Ontario Crash, March 1989
- Tokaimaura reprocessing accident, September 1999
- Texas City BP explosion, March 2005
- USS Stark incident, May 1987
- Iran Air Flight 655 shot down by USS Vincennes, July 1988
- Chatsworth train collision, September 2008
- artifacts (cognitive)
- bootstrapping
- cognitive work
- demands (cognitive)
- fixation
- goal conflicts
- human error
- model (mental)
- naturalistic decision making (NDM)
- operators
- process tracing
- recognition-primed decision (RPD)
- skills/rules/knowledge (SKR)
- teleology of the system
All references are just my best guesses from the context of the videos.
Cognitive work studies around safety/human performance draw from Three Mile Island:
- studies of people in simulators
- work studies
- incident reporting studies
- accident investigation studies
Joke in human factors: Until 1979, there were only two kinds of subjects that got any attention from human factors people:
- Someone died who shouldn't have (aircraft/transport systems)
- Someone didn't die who should have. (weapons system failure)
Researchers who studied Three Mile Island:
- Jens Rasmussen
- Morten Lind
- David Woods
- John Senders
- Neville Moray
- James Reason
- Charles Perrow
Existing theories about safety didn't explain how it was that the TMI operators could have been confused about what was actually happening in the plant.
The idea that human error was the cause because itself something that needed to be studied, and generated a whole series of new researches/quests/examinations on the topic of error itself
The operators believed they were doing the right thing, but had an incorrect model of the plant.
People were upset by TMI b/c there seem to have been multiple opportunities for people to have gotten the right diagnosis.
Three Mile Island (TMI): A report to the Commissioners and to the Public by the Rogovin Special Inquiry Group of the Nuclear Regulatory Commission (NRC). (The Rogovin report)
- Report of the Presdient's Commission on the Accident at Three Mile Island, Supplemental View by Thomas H. Pigford
- Report of the Presdient's Commission on the Accident at Three Mile Island, Supplemental View by Bruce Babbitt
- Jens Rasmussen, Coping with complexity
- Jens Rasmussen, Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models
- David Woods, Erik Hollnagel, Mapping cognitive demands in complex problem-solving worlds, Intenational Journal of Man-Machine Studies, Volume 26, Issue 2, 1987, Pages 257-275.
- Johnson Kochevar, Laura K. Kochevar, Paul E. Johnson, Problem Solving is What You Do When You Don't Know What to Do, Proceedings of the Tenth Annual Conference of the Cognitive Science Society, 1988.
Notes
- fundamental surprise (impossible accident, black swan)
- flexible, dynamic world of work
- it was all of the same researchers who studied TMI that studied Tokaimura as well
- safety experts are good at post-hoc analysis, but can't predict where the next accident will happen
- risks of doing cognitive task analysis:
- getting bogged down in the details of the domain
- going too narrow
- best way to get inside a domain is to look at the cognitive artifacts
- cognitive artifacts show the state of the world that matters to the operator
- if operator is creating cognitive artifacts during high tempo activities, a researcher can use the cognitive artifact to identify what the operator identifies as most important to pay attention to in the moment
- cognitive artifacts act as a map for researcher
- distributed cognition: sharing cognitive artifacts
- shared representation of the world
- surfaces mismatches between different operators' understanding of the world
- bootstrapping:
- cognitive task analysis has to be done iteratively
- going back and forth between person's view of the world and what's actually going on in the world
- Y. Fujita, Actualities Need to be Captured, Cognition, Technology & Work, Volume 2, Issue 4, November 2000
- N. Meshkati & J. Deato, Commentary on ‘Human Factor Analysis of JCO Criticality Accident’ by Furuta et al, Cognition, Technology & Work, Volume 2, Issue 4, November 2000
- C.P. Nemeth, R.I. Cook & D.D. Woods, The Messy Details: Insights from the Study of Technical Work in Healthcare, IEEE Transactions on Systems, Man, and Cybernetics - Part A: Systems and Humans, Volume: 34, Issue: 6, November 2004
- C.P. Nemeth, R.I. Cook, M. O'Connor & P.A. Klock, Using cognitive artifacts to understand distributed cognition, IEEE Transactions on Systems, Man, and Cybernetics - Part A: Systems and Humans, Volume: 34, Issue: 6, November 2004
- Scott S. Potter, Emilie M. Roth, David D. Woods, & William C. Elm, Bootstrapping Multiple Converging Cognitive Task Analysis Techniques for System Design, J.M.C., Chipman, S.F., & Shalin, V.L. (Eds.), Cognitive Task Analysis. Mahwah, NJ: Lawrence Erlbaum Associates, pp. 317-340.
Most references are from the following two special issues:
- Cognition, Technology & Work, Volume 2, Issue 4, November 2000. This is the special issue on the Tokaimura accident.
- IEEE Transactions on Systems, Man, and Cybernetics - Part A: Systems and Humans, Volume 34, Issue 6, November 2004
- Lisanne Bainbridge, Verbal reports as evidence of the process operator's knowledge, International Journal of Man-Machine Studies, Volume 11, Issue 4, 1979, Pages 411-436
- David Woods, Process tracing methods for the study of cognition outside the experimental psychology laboratory, 1993.
- K. Anders Ericsson and Herbert A. Simon, Verbal reports as data, Psychological Review, 87(3), 1980, 215–251.
(This lecture is missing)
Guest lecture by Professor Jeffrey Braithwaite.