17. Human Error, Error Generation Flashcards
Human Error, Error Generation
“an occassion where a planed sequence of mental or physical activities fails to achieve its intended outcome, and where these failures cannot be attributed to random external intervention”
This is the definition of what
ERROR
2
Human Error, Error Generation
Error is inextricably bound with what when carrying out an action
INTENTION
- The key to any definition of error is the concept of intention
- Error and intention are inextricably bound with each other
- There can be no error where there was no intention to carry out an action
2
Human Error, Error Generation
- Human error rates for simple repetative tasks are 1:____
- Human error rates for complex and stimulating tasks are 1:____
- 1:100
- 1:1000
2
Human Error, Error Generation
“where actions dont always go according to plan, such as dialling the wrong frequency into a radio”
This is the definition of what classification of error
SLIPS
4
Human Error, Error Generation
“Where the plan itself is fault. The person making the mistake believes that they are carrying out the correct action”
This is the definition of what classification of error
MISTAKE
4
Human Error, Error Generation
“When someone has failed to do something due to a lapse in memory and/or attention or because they have fogotten something. For example, forgetting to lower the landing gear”
This is the definition of what classification of error
LAPSE
4
Human Error, Error Generation
“When a person deliberately carries out an action knowing it to be contrary to the rules, law, or SOPs such as illegal low flying”
This is the definition of what classification of error
VIOLATION
4
Human Error, Error Generation
- MISTAKES or SLIPS are often subtle and complex
- MISTAKES or SLIPS are often quickly corrected
- MISTAKES
- SLIPS
- Slips are often quickly corrected because one of the main functions of consciousness is to monitor activity to detect divergence between action and intention
- Mistakes can pass unnoticed for a long time because the decision has been made and tends not to be questioned further
4
Human Error, Error Generation
“Relies on stored patterns of insutrctions (motor programmes). Errors commited at this level are largely connected with mis-timing, poor coordination or inappropriate force. These can be referred to as routine errors”
This is the definition of an error occuring at what skill based level
SKILL-BASED BEHAVIOUR LEVEL
4
Human Error, Error Generation
“associated with tackling familiar tasks which are governed by stored rules. At this level errors occur when the situation is miscalculated or misinterpreted and inappropriate rules are applied. A further source of error can result when the correct procedure is incorrectly remembered”
This is the definition of an error occuring at what skill based level
RULE-BASED BEHAVIOUR LEVEL
4
Human Error, Error Generation
“This level is concerned with solving new problems. The individual uses their experience to analyse the situation and devise a solution. Errors at this level stem from resource limitations and incomplete or incorrect knowledge”
This is the definition of an error occuring at what skill based level
KNOWLEDGE-BASED BEHAVIOUR LEVEL
4
Human Error, Error Generation
Skill-based behaviour level errors are associated with which of the following;
[ ] Incomplete knowledge
[ ] Mis-timing
[ ] Inappropriate force
[ ] Misinterpretation of rules
[ ] Inappropriate application of rules
[ ] Poor coordination
[ ] Incorrectly remembered procedure
[ ] Resource limitations
[ ] Incomplete knowledge
[X] Mis-timing
[X] Inappropriate force
[ ] Misinterpretation of rules
[ ] Inappropriate application of rules
[X] Poor coordination
[ ] Incorrectly remembered procedure
[ ] Resource limitation
4
Human Error, Error Generation
Rule-based behaviour level errors are associated with which of the following;
[ ] Incomplete knowledge
[ ] Mis-timing
[ ] Inappropriate force
[ ] Misinterpretation of rules
[ ] Inappropriate application of rules
[ ] Poor coordination
[ ] Incorrectly remembered procedure
[ ] Resource limitations
[ ] Incomplete knowledge
[ ] Mis-timing
[ ] Inappropriate force
[X] Misinterpretation of rules
[X] Inappropriate application of rules
[ ] Poor coordination
[X] Incorrectly remembered procedure
[ ] Resource limitations
4
Human Error, Error Generation
Knowledge-based behaviour level errors are associated with which of the following;
[ ] Incomplete knowledge
[ ] Mis-timing
[ ] Inappropriate force
[ ] Misinterpretation of rules
[ ] Inappropriate application of rules
[ ] Poor coordination
[ ] Incorrectly remembered procedure
[ ] Resource limitations
[X] Incomplete knowledge
[ ] Mis-timing
[ ] Inappropriate force
[ ] Misinterpretation of rules
[ ] Inappropriate application of rules
[ ] Poor coordination
[ ] Incorrectly remembered procedure
[X] Resource limitations
4
Human Error, Error Generation
- An error is a INTENDED or UNINTENDED deviation from normal performance
- A violation is a INTENDED or UNINTENDED deviation from normal performance
- UNINTENDED
- INTENDED
Human Error, Error Generation
A related sequence of errors which may lead to an accident or incident is known as what
ERROR CHAIN
6
Human Error, Error Generation
“A relatively short-lived failure which can be directly linked to an accident”
This is a definition of what sort of error
ACTIVE ERROR
12
Human Error, Error Generation
“Errors which lay dormant for some time before contributing to an accident”
This is a definition of what sort of error
LATENT ERROR
12
Human Error, Error Generation
Which of the following are considered internal errors;
[ ] Sensing errors
[ ] Cultural & Organisational factors
[ ] Perceptual errors
[ ] Action slips
[ ] Motivation and Arousal
[ ] High workload
[ ] Stressors
[ ] Decision-making
[ ] False-hypothesis
[ ] Distraction
[ ] Flight deck ergonomics
[X] Sensing errors
[ ] Cultural & Organisational factors
[X] Perceptual errors
[X] Action slips
[X] Motivation and Arousal
[ ] High workload
[ ] Stressors
[X] Decision-making
[X] False-hypothesis
[X] Distraction
[ ] Flight deck ergonomics
14/15
444/445
Human Error, Error Generation
Which of the following are considered external errors;
[ ] Sensing errors
[ ] Cultural & Organisational factors
[ ] Perceptual errors
[ ] Action slips
[ ] Motivation and Arousal
[ ] High workload
[ ] Stressors
[ ] Decision-making
[ ] False-hypothesis
[ ] Distraction
[ ] Flight deck ergonomics
[ ] Sensing errors
[X] Cultural & Organisational factors
[ ] Perceptual errors
[ ] Action slips
[ ] Motivation and Arousal
[X] High workload
[X] Stressors
[ ] Decision-making
[ ] False-hypothesis
[ ] Distraction
[X] Flight deck ergonomics
14/15
444/445
Human Error, Error Generation
Of all the defined internal error types, which is the most insidious and dangerous;
[ ] Sensing errors
[ ] Perceptual errors
[ ] Action slips
[ ] Motivation and Arousal
[ ] Decision-making
[ ] False-hypothesis
[ ] Distraction
[ ] Sensing errors
[ ] Perceptual errors
[ ] Action slips
[ ] Motivation and Arousal
[ ] Decision-making
[X] False-hypothesis
[ ] Distraction
- false hypothesis are easy to adopt and sometimes very difficult to relinquish
14/15
Human Error, Error Generation
The phenomenon associated with the end of a task which can lead to complacency is known as the what effect
END DETERIORATION EFFECT
(aka home-itis)
15
Human Error, Error Generation
The three main factors affecting external error generation in the cockpit are;
[ ] Ergonomics
[ ] Altitude
[ ] Time of day
[ ] Economics
[ ] Social Environment
[ ] Temperature
[X] Ergonomics
[ ] Altitude
[ ] Time of day
[X] Economics
[X] Social Environment
[ ] Temperature
- Ergonomics relates tot he design of the aircraft. It is ideal that all the key and primary flight equipment as example is directly in the pilots line of sight and reach rather than, say, behind them or over head
- Economics relates to thigns such as commercial pressures to fly on budget and on time
- Additionally economics relates to the reduction of crew resouces over time i.e. from 5 in the past to 2 now. With 2 pilots carrying out a wider range of activities
- Social environment expects the crew to work together safetly and effectively
16
Human Error, Error Generation
Errors arising from issues misreading or misinterpreting information on flight deck instruments is an error in what 2 elements of the SHELL model
LIVEWIRE < > HARDWARE
17
Human Error, Error Generation
When a checklist and operational manual are poorly written or poorly indexed, or instruments have multiple modes, this is an error between what 2 elements of the SHELL model
LIVEWIRE < > SOFTWARE
18
Human Error, Error Generation
Physical or psychological stressors significantly increasing the probably of error, such as noise, vibration, temperature and heat are examples of errors between what 2 elements of the SHELL model
LIVEWIRE < > ENVIRONMENT
19
Human Error, Error Generation
Deficiencies in teamwork and crew cooperation that can lead to disasterous break down in communications or poor relationships is an example of errors between what 2 elements of the SHELL model
LIVEWIRE < > LIVEWIRE (Peripheral)
20
