Applying a Dynamic Model of Situated Cognition to the Investigation of Mishaps

Complex systems will, inevitably, experience failures. The cause of these failures or mishaps may be labeled 'operator error,' but often they are actually caused by the confluence of technological, situational, individual, and organizational factors. Several models and theories of human error have been proposed over the years and are reviewed in this paper. The authors propose another model, the Dynamic Model of Situated Cognition (DMSC), to explain how complex systems fail. Miller and Shattuck (2004) developed the DMSC in an effort to link technological aspects of a system to the perceptual and cognitive aspects of that system. They illustrated the model by applying it to the USS Stark incident and to a military command and control simulation (Shattuck and Miller, 2004). The model also appears to have utility as a retrospective explanatory tool to identify when and where things went wrong. In this paper, the authors describe the DMSC as it relates to the analysis of error in complex systems and apply it to the February 2001 mishap in which the U.S. Navy submarine USS Greeneville collided with the Japanese motor vessel Ehime Maru off the coast of Oahu, Hawaii.