McDonald Joseph D, Durso Francis T
Georgia Institute of Technology, Atlanta
Georgia Institute of Technology, Atlanta.
Hum Factors. 2015 Sep;57(6):917-29. doi: 10.1177/0018720815584232. Epub 2015 Apr 27.
We investigated the effectiveness of a theoretically motivated intervention at reducing procedural errors in train yard operations, where making these errors could be costly or life-threatening.
A widespread and persistent memory error that people commit on a daily basis is the postcompletion error (PCE), that is, forgetting to complete the final step of a procedural task in which the final step occurs after completion of the task goal. PCEs occur in the railroad industry when a locomotive conductor changes the direction of a rail switch but fails to report this change. This particular error could contribute to unsafe conditions as another train traveling on the same track could derail. Although training can help reduce some of the factors leading to unsafe conditions on the rail, research has demonstrated that PCEs are different from other errors of omission in that they cannot be eliminated through training, which makes them a difficult problem to address.
Twenty-eight undergraduates completed train yard tasks within a mid-fidelity simulator used in commercial rail operations for training. Each participant received the behavioral intervention in one block and no intervention in another. Specifically, participants were required to perform an additional task designed to remind participants of the postcompletion step.
Our intervention significantly reduced PCE rates in the context of train yard operations, on average by 65%.
We discuss implications of the effectiveness of our intervention at reducing train yard accidents and how this outcome can contribute to the literature on the cause of PCEs.
In cases such as the railroad industry, where redesigning technology is prohibitive, our behavioral intervention is an effective alternative for significantly reducing PCEs.
我们研究了一种基于理论的干预措施在减少铁路调车场作业程序错误方面的有效性，在这种作业中，出现这些错误可能代价高昂或危及生命。
人们日常普遍存在且持续出现的一种记忆错误是完成后错误（PCE），即忘记完成程序任务的最后一步，而这最后一步是在任务目标完成之后出现的。在铁路行业中，当机车乘务员改变轨道开关方向但未报告此变化时，就会出现PCE。这种特定错误可能导致不安全状况，因为在同一轨道上行驶的另一列火车可能会脱轨。尽管培训有助于减少导致铁路不安全状况的一些因素，但研究表明，PCE与其他遗漏错误不同，因为它们无法通过培训消除，这使得它们成为一个难以解决的问题。
28名本科生在用于商业铁路运营培训的中等保真模拟器中完成铁路调车场任务。每个参与者在一个模块中接受行为干预，在另一个模块中不接受干预。具体而言，要求参与者执行一项额外任务，旨在提醒他们注意完成后的步骤。
我们的干预措施在铁路调车场作业环境中显著降低了PCE发生率，平均降低了65%。
我们讨论了干预措施在减少铁路调车场事故方面有效性的影响，以及这一结果如何为关于PCE成因的文献做出贡献。
在铁路行业等重新设计技术成本过高的情况下，我们的行为干预是显著降低PCE的有效替代方法。
