1 - Human Error

Question 1

What are the Dirty Dozen? Give examples of each and how they may reduce safety margins.

Answer 1

12 human factors that degrade peoples ability to perform safely and effectively, potentially leading to maintenance (or pilot) errors.

1. Lack of Communication
2. Complacency
3. Lack of Knowledge
4. Distraction
5. Lack of Teamwork
6. Fatigue
7. Lack of Resources
8. Pressure
9. Lack of Assertiveness
10. Stress
11. Lack of Awareness
12. Norms

Question 2

What is the Five M model

Answer 2

Management
Mission
huMan
Machine
Medium

Question 3

What is the definition of an error?

Answer 3

an action or inaction that leads to deviation from crew or organisational intentions or expectations

Question 4

What are the two types of errors? What are they typically caused by?

Answer 4

Active, usually caused by individual, has an immediate negative consequence

Latent, usually caused by system, consequence undetected and often surfaces at a later stage

Question 5

What is the difference between a error and a violation?

Answer 5

Error - unintentional, fails to achieve intended outcome

Violation - intentional, conscious decision which violates known rules, SOPs, etc

Question 6

What is a slip? what level SRK do they typically occur?

Answer 6

incorrect execution of an action in the execution stage, skill based

Question 7

What is a lapse? what level SRK do they typically occur?

Answer 7

failure of memory (storage stage), skill based

Question 8

What is a mistake? What level/s SRK do they typically occur?

Answer 8

plan is not correct, situation not correctly identified or does not have the knowledge of the correct solution

Knowledge and rule based (conscious decision making)

Question 9

What are the types of violations? what level SRK do they occur?

Answer 9

Routine - skill (normalised and common)
Situational - rule (shortcut at the expense of safety)
Exceptional - knowledge (unusual circumstance)

Question 10

What are the types of error management (5)?

Answer 10

Prevention - usually design based
Reduction - usually ergonomics
Tolerance - system tolerant of error
Recovery - easy to recover system after error
Detection - errors apparent asap, crosschecking

Question 11

What is at risk behaviour?

Answer 11

behavioural decision that increases risk where it is not recognised or believed to be justified

Question 12

What is high culpability behaviour?

Answer 12

conscious decision to deliberately disregard a substantial and unjustifiable risk

Question 13

What are the reason components of safety culture?

Answer 13

Informed/learning culture
Flexible culture
Just culture
Reporting culture