13. Human Error and Reliability Flashcards
Reliability and Decision Making
What is the term that describes a measure of the probability of a human committing an error
HUMAN RELIABILITY
411
Reliability and Decision Making
Actively and consciously choosing between 2 or more options is what
A DECISION
411
Reliability and Decision Making
What is the definition of a decision
ACTIVELY AND CONSCIOUSLY CHOOSING BETWEEN 2 OR MORE OPTIONS
411
Reliability and Decision Making
What are the 2 basic types of rational reasoning
- REASONING - Work out what you must do to achieve a certain goal
- LOGICAL REASONING - solve an abstract problem of logic
411
Reliability and Decision Making
Of the 2 basic types of rational reasoning, which one are humans typically good at
REASONING TO WORK OUT WHAT YOU MUST DO TO ACHIEVE A CERTAIN GOAL
411
Reliability and Decision Making
Of the 2 basic types of rational reasoning, which one are most people poor at
SOLVING PURE LOGIC PROBLEMS
411
Reliability and Decision Making
What are 3 common factors that the decision making process is influenced by;
- ____ : looking at the clock
- ____ : happy, sad, anxious
- ____ : looks dangerous
- TIME PRESSURE
- EMOTION
- ASSESSMENT OF RISK
411
Reliability and Decision Making
Time pressure is likely to lead to what sort of decision being taken
RISKIER
411
Reliability and Decision Making
Risk Assessment involves identifying ____, assessing the ____ of the threat occurring and then assessing the ____ of the threat
- POTENTIAL THREATS
- PROBABILITY
- SEVERITY
412
Reliability and Decision Making
Deciding to do something without going through a conscious evaluation of the options is an example of what
ACTING ON IMPULSE
413
Reliability and Decision Making
Decisions should ideally be what
Opposite to acting on impulse
RATIONAL
413
Reliability and Decision Making
Decision making can be influenced by what 6 factors;
- ____ : nice bubbly person
- ____ : leaning to this decision
- ____ : something that happened a long time ago
- ____ : high pressure workload
- ____ : lack of knowledge
- ____ : other individuals
- PERSONALITY : nice bubbly person
- BIAS : leaning to this decision
- PAST EXPERIENCE : something that happened a long time ago
- STRESS : high pressure workload
- TRAINING : lack of knowledge
- GROUP OF PEOPLE : other individuals
413
Reliability and Decision Making
What are the 9 complete stages of the decision making process;
- ____ : most important feature of the problem is identified along with the most desirable outcome
- ____ : gather as much of this as possible in the time available
- ____ : identify the degree of risk involved
- ____ : All options available
- ____ : weight up the consequences of options available
- ____ : which course of action to take
- ____ : execute
- ____ : observe
- ____ : was the decision valid
- DEFINE THE AIM : most important feature of the problem is identified along with the most desirable outcome
- COLLECT INFORMATION : gather as much of this as possible in the time available
- ASSESS THE RISK : identify the degree of risk involved
- DEVELOP OPTIONS : All options available
- EVALUATE THE OPTIONS : weight up the consequences of options available
- DECIDE : which course of action to take
- IMPLEMENT : execute
- MONITOR CONSEQUENCES : observe
- REVIEW : was the decision valid
414
Reliability and Decision Making
Good decision making requires what, which closely matchin the real-world situation
MENTAL MODELS
417
Reliability and Decision Making
When an incomplete mental model is formed, what is likely to occurr
ERRORS
417
Reliability and Decision Making
Errors occur as a result of what
INCOMPLETE MENTAL MODELS
417
Reliability and Decision Making
A mistake is a result of what
FAILED PLAN OF ACTION
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Reliability and Decision Making
A failed plan of action results in what
A MISTAKE
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Reliability and Decision Making
Faulty plans are a result of what
FAULTY DECISIONS
417
Reliability and Decision Making
An extreme situation that occurs suddenly with little warning is likely to trigger what in a pilot
STARTLE RESPONSE
417
Reliability and Decision Making
A startle response is associated with sudden what
As a result, individuals may suffer from significantly reduced ability to think effectively for how up to how long
- PHYSIOLOGICAL AROUSAL
- 60 SECONDS
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Reliability and Decision Making
The counter measure for a pilot flying (PF) to a startle response is to do what
DO NOTHING FOR A MOMENT
Fly the aircraft, take a deep breath, confirm stable flight path
417
Reliability and Decision Making
If a pilot flying (PF) is suffering from startle response, what should the pilo monitoring (PM) do
COMMUNICATE IMMEDIATELY
start communciating with the PF immediately
417
Reliability and Decision Making
There are 9 things which altogether are factors that influence and affect human reliability. Together, these are;
- ____ : roles defined and assigned to team members
- ____ : comfortablness of the flight deck
- ____ : organisation and layout of the cockpit
- ____ : well thought out SOPs
- ____ : workload
- ____ : the amount available affacts reliability
- ____ : Operating in the WOCL
- ____ : experience gained
- ____ : teamwork
- THE ORGANISATION : roles defined and assigned to team members
- WORKING CONDITIONS : comfortablness of the flight deck
- THE MAN-MACHINE INTERFACE : organisation and layout of the cockpit
- PROCEDURES AND PLANS : well thought out SOPs
- No. OF SIMULTANEOUS GOALS : workload
- AVAILABLE TIME : the amount available affacts reliability
- TIME OF DAY : Operating in the WOCL
- TRAINING and EXPERIENCE : experience gained
- CREW COLLABORATION : teamwork
- THE ORGANISATION : The quality of the roles defined and assigned to team members and sthe supporty given by the organisation
- WORKING CONDITIONS : The quality of the working conditions. For example, the comfortablness of the flight deck and the level of the noise or distraction
- THE MAN-MACHINE INTERFACE : A poorly designed or organised flight deck reduces the reliability of the crew
- PROCEDURES AND PLANS : Pre-determine, well thought out plans and procedures
- No. OF SIMULTANEOUS GOALS : The more tasks the individual must attend to, the less reliable they become
- AVAILABLE TIME :Amount of time available to execute the task
- TIME OF DAY : Operating in the WOCL
- TRAINING and EXPERIENCE : Training and experience improve human reliability
- CREW COLLABORATION : Effective team collaboration to reduce errors
418
Other decision making issues
Most of the time, human decisions are based on a combination of what 3 things;
- ____ : instinct
- ____ : came to rational decision
- ____ : past experience
- INTUATION
- REASONING
- HUNCH
418
Other decision making issues
What is the term known as where a professional makes a decision based on comparing the present situation with their past experience
RECOGNITION PRIMED DECISION MAKING
419
Other decision making issues
What is the name given to a particular type of decision-making bias that strongly favours continuing with a plan to get on the ground as soon as possible rather than reviewing the situation.
PLAN CONTINUATION BIAS
(get-home-itis)
420
Mental Models and Situation Awareness
What does the brain construct which are an approximate to reality
MENTAL MODELS
422
Mental Models and Situation Awareness
Why is mental modelling important i.e. what does it allow a pilot to do
DEAL QUICKLY WITH LARGE AMOUNTS OF INFORMATION
422
Mental Models and Situation Awareness
Mental model allows a pilot to better anticipate a situation. What is the advantage this brings
REDUCES WORKLOAD to AVOID MISTAKES
422
Mental Models and Situation Awareness
What is the name given to modelling of a situation
SITUATIONAL AWARENESS
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Mental Models and Situation Awareness
What is situational awareness
MODELLING OF A SITUATION
situationl awareness is the process of creating and maintaining an accurate mental model of your situation
422
Mental Models and Situation Awareness
On the occassions when the pilots situational awareness is good, what feeling will this give them
BEING IN CONTROL OF EVENTS
Thinking ahead of the aircraft
423
Mental Models and Situation Awareness
When situational awareness is lost, you may feel like events are what
IN CONTROL OF YOU
424
Mental Models and Situation Awareness
If a pilot feels that they are losing or have lost situational awareness, what are 5 things that they can do to regain it;
- ____ : burden of flying
- ____ : slow down
- ____ : understand where you are and where you will soon be
- ____ : think about the bigger picture
- ____ : make time to decide
- REDUCE YOUR WORKLOAD : burden of flying
- REDUCE THE PACE OF EVENTS : slow down
- REBUILD THE MENTAL PICTURE : understand where you are and where you will soon be
- STEP BACK : think about the bigger picture
- IMPROVE YOUR DECISION MAKING : make time to decide
- REDUCE YOUR WORKLOAD : Stabilise the flight path, engage autopilot to reduce burden of flying
- REDUCE THE PACE OF EVENTS : Increase track miles, alter course to slow down events before next essential event
- REBUILD THE MENTAL PICTURE : Use available aids to rebuild your mental picture
- STEP BACK : Mentally step back and try to think about the bigger picture
- IMPROVE YOUR DECISION MAKING : Take or make more time to decide. Resist temptation to take quick decisions
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Mental Models and Situation Awareness
In multi-crew situations, you must divide and apportion tasks, which means communication how with other crew members
CLEARLY and UNAMBIGUOUSLY
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Mental Models and Situation Awareness
when flying at night in very dark conditions, or in cloud, or both, your air picture is built up by what
ENTIRELY AND EXCLUSIVELY BY INTERPRETATION OF FLIGHT DISPLAYS
426
Mental Models and Situation Awareness
Which 2 displays give a pilot their orientation in 3D space when flying in dark, cloud, or both
- ATTITUDE INDICATOR
- ATTITUDE STRIP
426
Mental Models and Situation Awareness
Which 4 instruments give a pilot information about changes in state and energy level of the aircraft when flying in dark, cloud, or both
- SPEED STRIP
- ALTITUDE STRIP
- VERTICAL SPEED INDICATOR
- COMPASS
426
Mental Models and Situation Awareness
Which instrument gives a pilot the ability to situate the aircraft position in 2D space when flying in dark, cloud, or both
NAVIGATION DISPLAY
426
Mental Models and Situation Awareness
Which instruments gives a pilot information about the energy being given to, and used by, the aircraft when flying in dark, cloud, or both
THRUST INDICATORS
426
Mental Models and Situation Awareness
When information is missing or faulty, what happens to situational awareness and what is the risk
- SEVERELY DEGRADED
- SAFETY COMPROMISED
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Mental Models and Situation Awareness
What are the 2 major threats to situational awareness
- MISLEADING INFORMATION
- NO INFORMATION
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Mental Models and Situation Awareness
When trying to rebuild situational awareness, a pilot needs sufficient information to do one or possible 2 things. These are what
- REGAIN CONTROL OF AIRCRAFT (if lost)
- STABILISE FLIGHT PATH
428
Mental Models and Situation Awareness
The first foundation of situational awareness is to understand that an aeroplane is what
BROADLEY STABLE and USUALLY IN EQUILIBRIUM
428
Mental Models and Situation Awareness
The second foundation of situational awareness is to understand that an aeroplane obeys what
LAWS OF PHYSICS and AERODYNAMICS
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Mental Models and Situation Awareness
At night, what are 2 things you can do to potentially help regain situational awareness
- TURN DOWN INSTRUMENT LIGHTING
- LISTEN TO NOISE OF AIRFLOW
- Turning down instrument lighting may reveal a faintly visible horizon
- Listening to the noise of airflow can provide clues about your speed
428
Theory and Models of HUman Error
What is the definition of an error
A _planned_ sequence of mental or physical activities fails to achieve its intended outcome, where these failures cannot be attributed to random external intervention
439
Mental Models and Situation Awareness
What are the 2 main categories of human error called
- SLIPS / LAPSES
- MISTAKES
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Mental Models and Situation Awareness
In relation to human error, what is the definition of a slip
An error in which the intention was correct, but a failure occured when executing.
example, intending to stabilise the flight at 120 kts but doing so instead at 110 kts
439
Mental Models and Situation Awareness
In relation to human error, what is the definition of a mistake
An error arises from an incorrect intention, which leads to an incorrect action sequence
The action sequence may be consistent with the intention. For example, the execution of an action make be done so perfectly, but mistakenly.
439
Mental Models and Situation Awareness
The following is a definition of what sort of human error;
“An error which arises from an incorrect intention. This leads to an incorrect action sequence”
MISTAKE
439
Mental Models and Situation Awareness
The following is a definition of what sort of human error;
“An error in which the intention was correct but a failure occured when executing the activity”
SLIP
439
Mental Models and Situation Awareness
Faults happen to ____.
A fault IS or IS NOT a type of human error
- MACHINES
- IS NOT
439
Mental Models and Situation Awareness
Complete the following diagram
Options;
Mistakes | Violation | Uninntional | Intentional | Slips / Lapses | Violation
Mental Models and Situation Awareness
What is the definition of a violation
INTENTIONAL DEVIATION FROM CORRECT ACTION
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Mental Models and Situation Awareness
The intentional deviatoin from what is known to be the correct action is known as what
VIOLATION
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Mental Models and Situation Awareness
What are the 2 types of violation
- ROUTINE
- EXCEPTIONAL
441
Mental Models and Situation Awareness
What is the definition of an exceptional violation
ONE-OFF BREAKING OF THE RULES
442
Mental Models and Situation Awareness
An exceptional violation IS or IS NOT entirely voluntary
MAY or MAY NOT BE VOLUNTARY
depending on the underlying intentions
Example, pilot making an exceptional fiolation of flying below MDA because a faulty fuel gauge has resulting in him being well below diversion minima should not be diciplined in the same way as a pilot who intentionally violates MDA just “to get home”
442
Mental Models and Situation Awareness
Tragedies are not the result of a ____ but rather a sequence of ____ whose effects are ____.
- SINGLE ERROR
- INTERDEPENDENT ERRORS
- CUMULATIVE
442
Mental Models and Situation Awareness
“A relatively short-lived failure which can be directly linked to an accident”
This is a definition of what sort of error
ACTIVE
442
Mental Models and Situation Awareness
“Errors which lay dormant for some time before contributing to an accident”
This is a definition of what sort of error
LATENT
442
Mental Models and Situation Awareness
What is the definition of an active error
A relatively short-lived failure which can be directly linked to an accident
442
Mental Models and Situation Awareness
What is the definition of a latent error
Errors which lay dormant for some time before contributing to an accident
442
Mental Models and Situation Awareness
Many latent errors are as a result of what 2 things
- ORGANISATIONAL PROBLEMS
- CULTURE OF ORGANISATION
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Errors, Mistakes and Violations
Errors arising from factors specific tot he individual are known as what
INTERNALLY GENERATED ERRORS
444
Errors, Mistakes and Violations
What is the most significant cause of internally generated errors
FAULTY DECISION MAKING
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Errors, Mistakes and Violations
What are the 8 key sources of internally generated errors;
- ____ : brain hard wired
- ____ : forget corect action
- ____ : unable to process multiple sets of information at once
- ____ : cannot be bothered
- ____ : hypovigilance, long work hours, not enough sleep
- ____ : lack of practice
- ____ : unwell
- ____ : disorganised or unstructured
- PERCEPTUAL ERRORS : brain hard wired
- MEMORY FAILURE : forget corect action
- DISTRACTION : unable to process multiple sets of information at once
- LOW AROUSAL / POOR MOTIVATION : cannot be bothered
- FATIGUE : hypovigilance, long work hours, not enough sleep
- SKILL DETERIORATION : lack of practice
- ILLNESS : unwell
- POOR WORKLOAD MANAGEMENT : disorganised or unstructured
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Errors, Mistakes and Violations
What are the 4 sources of externally generated errors;
- ____ : anxiety, high workload, poor environmental conditions
- ____ : slack approach to discipline
- ____ : complicated SOPs
- ____ : interface between human and hardware
- STRESSORS : anxiety, high workload, poor environmental conditions
- CULTURAL & ORGANISATIONAL FACTORS : slack approach to discipline
- HIGH WORKLOAD : complicated SOPs
- FLIGHT DECK ERGONOMICS : interface between human and hardware
447
Errors, Mistakes and Violations
What externally generated error is the following a definition of;
“anxiety, high workoad, poor environmental conditions, or factors such as domestic or financial worries”
STRESSORS
447
Errors, Mistakes and Violations
What externally generated error is the following a definition of;
“Slack approach to discipline within the business, and a habit of ‘cutting corners’”
CULTURAL & ORGANISATIONAL FACTORS
447
Errors, Mistakes and Violations
What externally generated error is the following a definition of;
“complicated procedures on approach into a very busy aerodrome”
HIGH WORKLOAD
447
Errors, Mistakes and Violations
What externally generated error is the following a definition of;
“interface between humans and hardware is poorly designed”
FLIGHT DECK ERGONOMICS
447
Errors, Mistakes and Violations
Mistakes can occur at each and any stage in the decision making process. The 6 main sources of error are;
- ____ : predisposed to think a certain way
- ____ : perceived likelihood an event will occur or is associated with another event
- ____ : skill is frequently performed in the same environment, the environment causes the skill to be performed rather than a conscious decision
- ____ : group thinking
- ____ : stark refusal to admit that an event is happening
- ____ : anything reducing the mental capacity
- BIAS or CONFIRMATION BIAS : predisposed to think a certain way
- PROBABILITY & SALIENCY : perceived likelihood an event will occur or is associated with another event
- HABIT : skill is frequently performed in the same environment, the environment causes the skill to be performed rather than a conscious decision
- GROUP INFLUENCES : group thinking
- DENIAL : stark refusal to admit that an event is happening
- INFORMATION PROCESSING LIMITS : anything reducing the mental capacity
449
Errors, Mistakes and Violations
What are the 3 examples that can contribute to the error information processing limits;
- ____ : Physiological & psychological stress
- ____ : insufficient capacity to make a correct decision
- ____ : inexperienced decision making or over experience complacency
- STARTLE, SURPRISE & SHOCK : Physiological & psychological stress
- OVERLOAD & DISTRACTION : insufficient capacity to make a correct decision
- EXPERIENCE : inexperienced decision making or over experience complacency
449
Errors, Mistakes and Violations
What type of source of error is the following a definition of;
“Influenced by the perceived likelihood that an event will occur or is associated with another event”
PROBABILITY & SALIENCY
448
Errors, Mistakes and Violations
What type of source of error is the following a definition of;
“Predisposed to think in a certain way and look for reasons which confirm your decision rather than reject it”
BIAS & CONFIRMATION BIAS
448
Errors, Mistakes and Violations
What type of source of error is the following a definition of;
“a skill frequently performed in the same environment, the environment itslef can start to cause the skill to be performed ather than a conscious decision. This error is known as environmental capture”
HABIT
448
Errors, Mistakes and Violations
What type of source of error is the following a definition if;
“group thinking and behaviour being a very strong influence”
GROUP INFLUENCES
448
Errors, Mistakes and Violations
What type of source of error is the following a definition of;
“Stark refusal to admit that the stress-inducing event is happening at all”
DENIAL
449
Errors, Mistakes and Violations
What type of source of error is the following a definition of;
“Anything that reduces mental capacity i.e. startle, surprise and shock, or overland and distraction, or experience”
INFORMATION PROCESSING LIMITS
449
Errors, Mistakes and Violations
What is the name given to the error associated with habit where a skill is performed as a result of the environment itself and not a conscious decision
ENVIRONMENTAL CAPTURE
448
PAGE 453 - UPLOAD DIAGRAM!!!!!!!
Error Management Strategies
What was the most unsuccessful management strategy used in the past
ZERO DEFECT PROGRAMME
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Error Management Strategies
Error Reduction or Error Cause removal programs try to do what
ANTICIPATE THE CAUSE OF ERRORS
remove errors before they strike
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Error Management Strategies
What are 4 error prevention strategies adopted today;
- ____ : system taking over monotonous or routine activities
- ____ : errors become quickl and clearly noticable
- ____ : techniques concentrating on being able to reverse actions quickly
- ____ : reducing consequences when an error occurs
- AUTOMATION : system taking over monotonous or routine activities
- ERROR DETECTION : errors become quickl and clearly noticable
- ERROR RECOVERY : techniques concentrating on being able to reverse actions quickly
- ERROR TOLERANCE : reducing consequences when an error occurs
455
Error Management Strategies
What are 3 methods of error detection
- BY THE INDIVIDUAL
- ON-BOARD SYSTEMS
- OTHER INDIVIDUALS (flight crew, passengers)
455
Error Management Strategies
The following is a definition of what error prevention strategy;
“systems taking over monotonos or routine activities”
AUTOMATION
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Error Management Strategies
The following is a deinition of what error prevention strategy;
“errors identified by individuals or onboard systems”
ERROR DETECTION
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Error Management Strategies
The following is a definition of what error prevention strategy;
“techniques concentrating on being able to reverse actions quickly to undo an error”
ERROR RECOVERY
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Error Management Strategies
The following is a definition of what error prevention strategy;
“reducing the consequences of an error by design”
ERROR TOLERANCE
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Error Management Strategies
What are the 3 strands of error countermeasures
- LINE OPERATION SAFETY AUDIT (LOSA)
- FLIGHT OPERATIONAL QUALITY ASSURANCE (FOQA)
- EVIDENCE BASED TRAINING (EBT)
457
Error Management Strategies
What error countermeasure is the following a definition of;
“Observer collects data about pilot behaviour and its context, conducted under a strict no-jeopardy condition”
LINE OPERATIONS SAFETY AUDIT (LOSA)
456
Error Management Strategies
What error countermeasure is the following a definition of;
“Flight Data Monitoring (FDM). Using digital recording devices to capture data about every flight and using analytical software to interpret the data”
FLIGHT OPERATIONAL QuALITY ASSURANCE (FOQA)
457
Error Management Strategies
What error countermeasure is the following a definition of;
“mandatory simulator training conducted, each session being tailored to the individual”
EVIDENCE BASED TRAINING (EBT)
457
Ergonomics
The study of designing equipment and devices that fit the human body is known as what
ERGONOMICS
458
Ergonomics
What is the design eye point known as that the flight deck is designed around
EYE DATUM / REFERENCE VIEW POINT
459
Ergonomics
The selection and display of what 3 vital and frequently adjusted parameters are always in sight and within reach of the pilot
- HEIGHT
- HEADING
- SPEED
461
Ergonomics
Controls are grouped by what
FUNCTION
462
Ergonomics
Controls may be what in order to make them easier to select by touch rather than by sight
SHAPED
463
Ergonomics
Instruments are group according to what
FUNCTION
464
Ergonomics
The “Basic T” comprises what what 6 major instruments
- ALTIMETER
- ATTITUDE INDICATOR
- COMPASS
- AIRSPEED INDICATOR
- TURN INDICATOR
- VERTICAL SPEED INDICATOR
464
Ergonomics
What are digital displays commonly used to display and why
- QUANTITIES & VALUES
- PRECISE VALUES REQUIRED
engine temperature and fuel quantity typically digital displays
465
Ergonomics
Symbology & visual indocators; Humans naturally associated what with different states
COLOURS
468
Ergonomics
RED typically represents ____
GREEN typically represents ____
- DANGER
- OK or SAFE
468
Ergonomics
Modern flight decks use what sort of system to alert pilots visually
CENTRALISED WARNING SYSTEM
(CWS)
469
Ergonomics
What is the name of the system that usually comprises of a flashing master caution light accompanied by an audio warning
ATTENTION GETTING SYSTEM
470
Ergonomics
The human brain is better at gathering information when presented how, as opposed to what
- GRAPHICALLY
- WORDS or LISTS
471
A method of design used to reduce the incidence of action slips
STANDARDISATION
473