TA Vulnerability Analysis Karen Clarke John Dobson Ian Somerville Peter Wright Angie Miguel

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TA Vulnerability AnalysisKaren ClarkeJohn
DobsonIan SomervillePeter WrightAngie
Miguel others you know who you are
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What?

• This TA is concerned with developing a method of
  process assessment in socio-technical systems
  with the aim of discovering vulnerable areas of
  these processes in order to produce a method of
  identifying potential failure points at the
  design stage of a system

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PERE- shaped approach

• The PERE methodology as a general approach to
  analysing process vulnerabilities which was
  developed in the context of REAIMS and builds on
  work by Reason, Rasmussen and others.
• Work at Newcastle carried out over some years by
  John Dobson which has developed a method for
  analysing weaknesses in responsibility and
  communication structures within and between
  organisations. This method fits nicely into and
  complements the PERE methodological framework.
• initial plan was to simply integrate these
  approaches in order to form a systematic method
  for analysing process vulnerabilities in
  socio-technical systems

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PERE and viewpoints

• Mechanistic - process modelling
• Human Factors - question-based
• Improving Knife to Skin Time
• Chasing Empties
• Problems of component parts
• Group vs Individual activities

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From PERE to CHLOE

• CHLOE has been designed by Angie Miguel as a
  technique to help identify possible failures in
  collaborative work both between people and/or
  people and information systems. The CHLOE method
  consists of four stages
• Scenario Description
• Task Identification
• Error Analysis
• Design Suggestions

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CHLOE for DIRC?

• CHLOE technique has now been evaluated using
  existing fieldwork material from the
  hospital-based studies - workarounds, bed
  management etc

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Conflicting Interests and Wobbly Legs

• Scenario One Orientation to financial targets
• Agents Directorate Manager, Management
  Information System (MIS), Data Management
  Section, Ward Manager, Finance Director .
• Essential Tasks identify appropriate patients,
  assess resources, pre-op assessments, timely
  billing.
• Problems of goal decomposition.

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Question Time

• Perception Question Is the necessary information
  to carry out their tasks available to each
  participant in a way that is immediately obvious
  and meaningful to them?
• Goals Question Is each participant able to see a
  fully up to date version of (the state of) the
  system?
• Planning Question Is extensive coordination and
  planning required on the spot by several
  participants in order to successfully carry out
  the task without conflicts or are actions
  pre-planned and practiced?
• Actions Question If this action is left
  incomplete/incorrect, will it prevent the
  completion of other actions and/or cause the
  whole task to fail (directly or indirectly)?

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From ethnography to design again

• Design Suggestions
• 1. Laptops for managers who carry out multi-site
  working such that they could access e-mail, MIS
  etc.
• 2. Upgraded phone system to ease inter-site
  communications
• 3. Although MIS data could never be fully
  accurate and up to date it should be possible to
  improve on the current situation.

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From PERE to Where

• Problems of using existing ethnographic data
• There are general problems with the questions in
  that most are very complicated and can be
  interpreted in a range of ways
• The answers to a lot of questions, even ignoring
  the problems in the questions themselves, are of
  the sometimes, maybe, how would I know
  order
• Tendency to look for an ideal how things ought
  to be world, rather than dealing with how
  things are and obsession in computing with up to
  date and accurate information
• Rewrite the questions and/or change to prompts?
• Responsibility theme