15 Human Error And Decision Making Flashcards
Define an Error
An intention and result of a pilot action do not match
An action which has resulted in less than optimum performance
How often do humans make errors and according to Frank Hawkins with good training what could this change to?
- 1 error in every 100 actions
- 1 error in every 1000 actions
How often do computers make errors?
1 error in every 10,000,000 actions
Is it inevitable that humans will make mistakes?
Yes, Humans are fallible to errors
What two categories can Errors be split into?
- Action Slips: Operators intent was correct but the result does not match the operators intent
- Faults or Mistakes: Operators intent is incorrect but the result does match the operators intent
Describe Omissions and Violations, give the types of Violations
- Omissions: where something is unintentionally missed
- Violations: where something is intentionally done not to the rules
- Routine Violations
- Exceptional Violations
Describe the two types of errors
Latent Errors:
- Do not effect the flight immediately
- False sense of security
- Hard to identify
Active Errors:
- Immediate impact on flight
What is Murphy’s law?
Anything that can go wrong, will go wrong
If a system can be operated incorrectly, it will be
Describe the Swiss Cheese model or The Error Chain by James Reason
- A chain of error prevention and error traps are put in place
- If an error manages to get through the a stage it weakens the chain
- If an error gets through all of the stages this leads to an accident
Describe the different types of Error Generation
- Sensing Error: Sense fails to pick up a stimulus
- Perception/Interpretation Error: Fail to correctly interpret a stimulus
- False Hypothesis/Confirmation Bias Errors: Ignore a stimulus
- Decision Making Errors: Miss understand a stimulus
Describe the two types of Distraction
- Channel Distraction: Focussed on one item so much that everything else gets ignored
- Disbursed Distraction: Trying to focus on too many things at once
Describe the SHELL model
Liveware to Software: Check lists, manuals
Liveware to Hardware: Instruments, controls, flight deck design
Liveware to Environment: Weather, deadlines, economics
Liveware to Liveware: Interaction between crew members, MCC, CRM
How much harder where 3 point altimeters to read and what percentage did they increase errors by?
- 3 times harder to read
- increased errors by 20%
What are the ways of reducing errors?
- Cross-monitoring: pilots cross-check each other
- Reversible Errors: undoing errors before they happen
- Error Prevention: training, and briefings to prevent errors
- Machine Monitoring: systems warn of a possible error
Describe Threat Error Management (TEM) and describe the difference between a Threat and an Error
- Detecting, preventing and responding to errors and threats
- Threat is an event beyond the control of the crew
- Error is where an operators intent and the result are not the same
