Errors: An Inherent Part of Human-System Performance - Foundations for Designing User-Centered Systems - page 289

Mistakes

Rule-based

Slips

Knowledge-based

Interpretation Planning Acting

Stimulus
Evidence

Situation
Assessment

Intention of
Action

Action
Execution

Lapses and
Mode Errors

Memory

Fig. 10.2 Reason's Generic Error Modelling System (GEMS) error types related to a simple
stage model of human information processing (adapted from Wickens and Holland 2000 )

10.3.3 The Cognitive Reliability and Error Analysis Method

Hollnagel's ( 1998 ) Cognitive Reliability and Error Analysis Method (CREAM)
tacitly acknowledges the fact that there is no single ideal taxonomy. Instead, the
CREAM provides a generic framework for developing a domain specific taxon-
omy of causes and effects of erroneous actions.
In the CREAM, performance takes place in a context that is defined by the
interaction between three high level factors:

1. The human operator
2. The technology (usually the system being operated by the human)
3. The wider organization (including the environment in which the system is
located).
Each of these factors is explicitly accounted for in the CREAM that includes a
scheme for classifying actions and events. The CREAM also takes account of the
current consensus view that there is not a separate uniquely identifiable part of the
human physiology that can be conveniently labeled error generator. As noted
earlier, in many cases erroneous behavior occurs when the user takes what appears
to be the appropriate action in conditions that are similar to, but not quite the same
as what the operator believes them to be.
Any erroneous actions that can be detected can be categorized as belonging to
one or more of eight possible error modes or effects—Hollnagel ( 1993b ) also