17. Understanding Error and Error Countermeasures Flashcards
The SHELL Model
What are the 5 factors in the aviation environment that the SHELL model is based upon
- SOFTWARE
- HARDWARE
- ENVIRONMENT
- LIVEWIRE (central)
- LIVEWIRE (peripheral)
604/605
The SHELL Model
The following is a defintiion of which of the 5 factors in the aviation environment that the SHELL model is based upon;
“Non-physical elements such as organisational policies, procedures, manuals, checklist layout, charts, maps, advisories and computer programmes”
SOFTWARE
hardware
environment
livewire (central)
livewire (peripheral)
604
The SHELL Model
The following is a defintiion of which of the 5 factors in the aviation environment that the SHELL model is based upon;
“Equipment including aircraft systems, workstations, displays, controls etc..”
software
HARDWARE
environment
livewire (central)
livewire (peripheral)
604
The SHELL Model
The following is a defintiion of which of the 5 factors in the aviation environment that the SHELL model is based upon;
“internal and external climate. Covers items such as temperature, visibility, vibration, noise etc.. Also covers broader environmental aspects such as political and economic constraints”
software
hardware
ENVIRONMENT
livewire (central)
livewire (peripheral)
604
The SHELL Model
The following is a defintiion of which of the 5 factors in the aviation environment that the SHELL model is based upon;
“The human element. Considered the most valuable and flexible component, it is placed in the centre of the model. Capabilities of the human element are determined by physical, physiological, psychological, or psychosocial factors.”
software
hardware
environment
LIVEWIRE (central)
livewire (peripheral)
605
The SHELL Model
The following is a defintiion of which of the 5 factors in the aviation environment that the SHELL model is based upon;
“Refers to the systems of human-human interactions, such as management, supervision, crew interactions and communications”
software
hardware
environment
livewire (central)
LIVEWIRE (peripheral)
605
The SHELL Model
The interaction between liveware and hardware is commonly known as what
MAN-MACHINE INTERFACE
606
The SHELL Model
The design ofcontrols and displays are closely matched to human characterstics and expectancies in order to do what
MINIMIZE ERRORS
for example, modern aircraft, the landing lever is shaped like a landing wheel
606
The SHELL Model
In the L-S interaction, what is an overly complex chart layout liable to and therefore could lead to errors
MISINTERPRETATION
607
The SHELL Model
In the L-L interaction, one of the most common causes of catastrophic error is ____ between crew and ATC, often as a result of poor ____
- MISUNDERSTANDINGS
- LANGUAGE SKILLS
608
The SHELL Model
In the L-E interaction, noise, heat, and vibration degrade human performance because it increases ____ discomfort and impacts ____
- PHYSIOLOGICAL
- DECISION MAKING
610
The SHELL Model
In the L-E interaction, adverse weather conditions are implicated in ____% of fatal accidents
23%
610
The SHELL Model
2 systems in the cockpit which enhance the L-E interaction and provide additional layers of protection
- GROUND PROXIMITY WARNING SYSTEM (GPWS)
- AIRBORNE COLLISION AVOIDANCE SYSTEM (ACAS)
611
The SHELL Model
In the L-E interaction, an organisation which imposes severe penaltities on pilots who unintentionally commit errors may cause what within pilots, and may lead to them doing what
- UNREASONABLE STRESS LEVELS
- SECRECY, COVERING UP MISTAKES
611
The SHELL Model
In the L-E interaction, the following is a definition of what sort of business model;
“An organisation that allows mistakes to be reported without risk of sanctions, allows others ot benefit from the knowledge”
OPEN CULTURE
611
Reasons Swiss Cheese Model
The Reasons Swiss Cheese Model distinguishes what 2 categories of accidents
- INDIVIDUAL
- ORGANISATIONAL
612
Reasons Swiss Cheese Model
The following is a defintiion of which of the 2 categories of accident within the Reasons Swiss Cheese Model;
“The accident usually has limited consequences but may be very damaging to the individual involved”
INDIVIDUAL ACCIDENTS
612
Reasons Swiss Cheese Model
The following is a defintiion of which of the 2 categories of accident within the Reasons Swiss Cheese Model;
“Multiple causes, involving multiple people. Relatively rare but their effets may be devestating”
ORGANISATIONAL ACCIDENTS
612
Reasons Swiss Cheese Model
What is the big difference between the 2 types of accidents identified in the Reasons Swiss Cheese Model, inidividual and organisational
NUMBER AND QUALITY OF DEFENSES IN PLACE
612
Reasons Swiss Cheese Model
In an individual accident, the individual is very close to the ____ and may have ____ between them and it
- HAZARD
- NO DEFENSES
example - tree surgeon operating a chain saw
613
Reasons Swiss Cheese Model
In organisational accidents, the industries often have a great number of multi layered defenses in place. This is know as what
DEFENSE IN DEPTH
614
Reasons Swiss Cheese Model
What is a key problem in relation to the risks involved in an organisational accident
NOT READILY AND IMMEDIATELY APPARENT TO OPERATORS
614
Reasons Swiss Cheese Model
In th Reasons Swiss Cheese Model, defenses against error are depitcted as a seris of physical barriers. Each barrier represents ____ and ____ designed to prevent error
- SYSTEMS
- PROCESSES
617
Reasons Swiss Cheese Model
If enough holes of sufficient size in each of the barriers of the Reasons Swiss Cheese Model align, this creates an opening known as what
TRAJECTORY OF ACCIDENT OPPORTUNITY
617
Reasons Swiss Cheese Model
Holes in each slide of of the Reasons Swiss Cheese Model represent what 2 types of error
- ACTIVE
- LATENT
617
Reasons Swiss Cheese Model
Holes representing latent errors in the Reasons Swiss Cheese Model are relatively ____.
The more holes there are, the more likely what will happen
- STATIONARY
- ALIGNMENT - allowing accident path to develop
617
Reasons Swiss Cheese Model
What is the name given to the type of industry, such as mining, where the dangers are very obvious to all involved
UNSOPHISTICATED
617
Reasons Swiss Cheese Model
What is the name given to the type of industry, such as aviation, where critical errors do not occur often and people may forget to be afraid of risks
SOPHISITCATED
617
Reasons Swiss Cheese Model
In a defense in depth environment, human controllers of the system are situated how in relation to the hazard
REMOTE FROM THE HAZARD
619
Reasons Swiss Cheese Model
In a defense in depth environment, what is an issue that contributes to making it impossible for any one person to understand ‘it all’.
COMPLEXITY
619
Reasons Swiss Cheese Model
A combination of what 2 things allow laten errors to start to buil up in each layer of defense
- COMPLACENCY
- IGNORANCE
619
Reasons Swiss Cheese Model
What is the only influence that can be exerted on various levels of defense within an organisation to reduce the liklihood of a build up of latent errors
SAFETY CULTURE
619
Threat and Error Management
The following is a definition of what component within the TEM model;
“Events or errors that occur beyond the influence of the flight crew, which increase operational complexity, andw hich must be managed to maintain the margins of safety”
THREATS
620
Threat and Error Management
The following is a definition of what component within the TEM model;
“Actions or inactions by the flight crew that lead to deviations from organisational or flight crew intentions or expectations”
ERRORS
620
Threat and Error Management
The following is a definition of what component within the TEM model;
“Any crew-induced position or speed deviations, misapplication or flight controls, or incorrect ssytems configuration, which causes a reduction in safety margins”
UNDESIRED AIRCRAFT STATE
620
Threat and Error Management
Complete the following diagram
OPTIONS
Undesired Aircraft State | Threats | Countermeasures | Errors
Threat and Error Management
What are the 2 main categories of threat in the TEM model
- ENVIRONMENTAL
- ORGANISATIONAL
622
Threat and Error Management
The following is a definition of which of the 2 types of threat category identified in the TEM model;
“occur due to the environment in which the flight operations take place. Must be managed by the flight crews in real time”
ENVIRONMENTAL THREAT
622
Threat and Error Management
The following is a definition of which of the 2 types of threat category identified in the TEM model;
“Flight crews are the last line of defence, but there are earlier opportunities for these threats to be mitigated by the company”
ORGANISATIONAL THREAT
622
Threat and Error Management
The manner in which threats can occur can be defined in what 3 ways;
- ____ : expected or known
- ____ : in-flight aircraft malfunction that happens without warning
- ____ : not directly obvious or observable
- ANTICIPATED
- UNEXPECTED
- LATENT
622
Threat and Error Management
What are the 3 categories of errors in the TEM model
- AIRCRAFT HANDLING ERROR
- PROCEDURAL ERROR
- COMMUNICATION ERROR
624
Threat and Error Management
The following is a definition of which of the 3 categories of error in the TEM model;
“Caused by an interaction between the pilot and the aircraft through various controls”
AIRCRAFT HANDLING ERROR
procedural error
communication error
624
Threat and Error Management
The following is a definition of which of the 3 categories of error in the TEM model;
“caused by the interaction between a pilot and a checklist or SOP”
aircraft handling error
PROCEDURAL ERROR
communication error
624
Threat and Error Management
The following is a definition of which of the 3 categories of error in the TEM model;
“caused by the interaction between the pilot and other people such as ATC or ground crew”
aircraft handling error
procedural error
COMMUNICATION ERROR
624
Threat and Error Management
The following is a definition of what in the TEM model;
“Transitional states between a normal operationa state and an outcome”
UNDESIRED AIRCRAFT STATE
626
Threat and Error Management
What are the 2 categories of outcome from a transition from a normal state into an undesired aircraft state
- INCIDENT
- ACCIDENT
626
Threat and Error Management
Undesired aircraft states are categorised by type. What are the 3 types of category
- AIRCRAFT HANDLING
- GROUND NAVIGATION
- INCORRECT AIRCRAFT CONFIGURATION
626
Threat and Error Management
The following is a definition of which of the 3 undesired aircraft states;
“aircraft control, veritical, lateral or speed deviations. Uneccessary weather penetration. Unauthorised airspace penetration. Operation outside aircraft limitations. Unstable approach. Continued landing after unstable approach, floated, firm or off centerline landing”
AIRCRAFT HANDLING
ground navigation
incorrect aircraft configuration
626
Threat and Error Management
The following is a definition of which of the 3 undesired aircraft states;
“Proceeding towards wrong taxiway or runway. Wrong taxiway, ramp, gate or hold spot”
aircraft handling
GROUND NAVIGATION
incorrect aircraft configuration
626
Threat and Error Management
The following is a definition of which of the 3 undersired aircraft states;
“incorrect systems configuration. Incorrect flight controls configuration. incorrect automation configuration. Incorrect engine configuration. Incorrect weight and balance configuration”
aircraft handling
ground navigation
INCORRECT AIRCRAFT CONFIGURATION
626
Threat and Error Management
Countermeasures in the TEM model are categorised into what 2 methods
- SYSTEMIC
- INDIVIDUAL
627
Threat and Error Management
The following is a definition of which of the 2 countermeasures categories used in the TEM model;
“(hard) countermeasures introduced into a system to counter a specific threat”
SYSTEMIC
Example - stick-pusher system to indicate stall behaviour in a swept wing aircraft
627
Threat and Error Management
The following is a definition of which of the 2 countermeasures categories used in the TEM model;
“countermeasures you take to protect your aircraft from threats and errors. Requires you to identify the threats associated with particular operation, or phase of an operation so you can plan and implement countermeasures”
INDIVIDUAL
Example - reading a METAR or TAF and delaying arrival time at an airfield so as to avoid a thunderstorm
627
Safety Culture
The term used to define the culture within an organisation that is defined by attitudes, beleifs, perceptions and values that employees share to safety
SAFETY CULTURE
628
Safety Culture
Individuals are influenced by what in regards to where they live and grow up
NATIONAL CULTURE
634
Positive Safety Culture
The foundation of a positive safety culture is what
INFORMED CULTURE
636
Positive Safety Culture
What is the first requirement in creating an informed culture which is itself the foundation of a positive safety culture
REPORTING SYSTEM
636
Positive Safety Culture
Where an organisation has a reporting system in place in order to promote an informed culture, which is the foundation of a positive safety culture, individuals must feel able and willing to report incidents. This is known as what
REPORTING CULTURE
636
Positive Safety Culture
What are the 5 key elements that are required to promote a positive reporting culture
- ____ : Reports must be confidential and de-identified
- ____ : agency collecting analysis reports must be separate from the agency responsible for diciplinary action
- ____ : must be rapid, useful, accessible and intelligible
- ____ : mechanisms must make it easy for reporters to complete and file
- ____ : aboveall else, this is vitally important
- ANONYMITY : Reports must be confidential and de-identified
- UNBIASED AGENCIES : agency collecting analysis reports must be separate from the agency responsible for diciplinary action
- FEEDBACK : must be rapid, useful, accessible and intelligible
- EASE OF REPORTING : mechanisms must make it easy for reporters to complete and file
- TRUST : aboveall else, this is vitally important
636
Positive Safety Culture
A process by which people can learn from the mistakes and near mistakes of others
FEEDBACK
636
Positive Safety Culture
A cultural dicipline required in order to benefit from the feedback from others mistakes and near mistakes
LEARNING CULTURE
636
Positive Safety Culture
Trust is the product of what sort of culture, which therefore makes it one of the most important components of a positive safety culture
JUST CULTURE
637
Positive Safety Culture
A just culture is one in which all members of the organisation ____ the boundary between ____ behaviour
- KNOW & UNDERSTAND
- ACCEPTABLE & UNACCEPTABLE
637
Positive Safety Culture
A just culture IS or IS NOT a no-blame culture in which reckless actions and deliberate non-compliance must be punished
IS NOT
637
Positive Safety Culture
A just culture IS or IS NOT a punitive culture in which all errors are punished
IS NOT
637
Positive Safety Culture
What are the 5 cultural elements that make up a positive safety culture
Myth of Safety First
What are the 3 elements that make up recurrent accidents
- UNIVERSAL
- LOCAL TRAPS
- DRIVERS
639
Myth of Safety First
The following is a definition of which of the 3 elements that make up recurrent accidents;
“ever present hazards such as weather and terrain”
UNIVERSAL
local traps
drivers
639
Myth of Safety First
The following is a definition of which of the 3 elements that make up recurrent accidents;
“particular characteristics of the task that lure people into making mistakes i.e. misreading ambiguous or unclear information on an approach chart”
universal
LOCAL TRAPS
drivers
639
Myth of Safety First
The following is a definition of which of the 3 elements that make up recurrent accidents;
“unsafe aspects of an organisations culture that focuses people towards the local traps. i.e. cost cutting measures which lead to poor training”
universal
local traps
DRIVERS
639
Safety Management System (SMS)
A systematic approach to managing safety in an organisation, including organisational structures, accountabilities, policies and procedures
SAFETY MANAGEMENT SYSTEM
(SMS)
640
Safety Management System (SMS)
An SMS system encompasses what 3 factors
- TECHNICAL
- HUMAN
- ORGANISATIONAL
640
