17. Understanding Error and Error Countermeasures Flashcards by C MC

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

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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

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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

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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

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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

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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

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The SHELL Model

The interaction between liveware and hardware is commonly known as what

MAN-MACHINE INTERFACE

606

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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

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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

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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

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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

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The SHELL Model

In the L-E interaction, adverse weather conditions are implicated in ____% of fatal accidents

23%

610

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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

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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

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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

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Reasons Swiss Cheese Model

The Reasons Swiss Cheese Model distinguishes what 2 categories of accidents

INDIVIDUAL
ORGANISATIONAL

612

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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

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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

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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

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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

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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

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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

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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

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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

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# Reasons Swiss Cheese Model Holes in each slide of of the Reasons Swiss Cheese Model represent what 2 types of error

1. ACTIVE 2. LATENT ## Footnote 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

1. STATIONARY 2. ALIGNMENT - allowing accident path to develop ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 619

# Reasons Swiss Cheese Model A combination of what 2 things allow laten errors to start to buil up in each layer of defense

1. COMPLACENCY 2. IGNORANCE ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 620

# Threat and Error Management Complete the following diagram [TEM](https://drive.google.com/file/d/1piiC6aFzx6joSFPnN4eYAno52t7RAHD7/view?usp=drive_link) **OPTIONS** Undesired Aircraft State | Threats | Countermeasures | Errors

1. THREATS 2. ERRORS 3. COUNTERMEASURES 4. UNDESIRED AIRCRAFT STATE [COMPLETED](https://drive.google.com/file/d/1mxCxECjbiGY1gzK2ISqbL2yEVA13Szwv/view?usp=drive_link) ## Footnote 621

# Threat and Error Management What are the 2 main categories of threat in the TEM model

1. ENVIRONMENTAL 2. ORGANISATIONAL ## Footnote 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 ## Footnote 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 ## Footnote 622

# Threat and Error Management The manner in which threats can occur can be defined in what 3 ways; 1. ____ : expected or known 2. ____ : in-flight aircraft malfunction that happens without warning 3. ____ : not directly obvious or observable

1. ANTICIPATED 2. UNEXPECTED 3. LATENT ## Footnote 622

# Threat and Error Management What are the 3 categories of errors in the TEM model

1. AIRCRAFT HANDLING ERROR 2. PROCEDURAL ERROR 3. COMMUNICATION ERROR ## Footnote 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 ## Footnote 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 ## Footnote 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** ## Footnote 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 ## Footnote 626

# Threat and Error Management What are the 2 categories of outcome from a transition from a normal state into an undesired aircraft state

1. INCIDENT 2. ACCIDENT ## Footnote 626

# Threat and Error Management Undesired aircraft states are categorised by type. What are the 3 types of category

1. AIRCRAFT HANDLING 2. GROUND NAVIGATION 3. INCORRECT AIRCRAFT CONFIGURATION ## Footnote 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 ## Footnote 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 ## Footnote 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** ## Footnote 626

# Threat and Error Management Countermeasures in the TEM model are categorised into what 2 methods

1. SYSTEMIC 2. INDIVIDUAL ## Footnote 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 ## Footnote 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 ## Footnote 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 ## Footnote 628

# Safety Culture Individuals are influenced by what in regards to where they live and grow up

NATIONAL CULTURE ## Footnote 634

# Positive Safety Culture The foundation of a positive safety culture is what

INFORMED CULTURE ## Footnote 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 ## Footnote 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 ## Footnote 636

# Positive Safety Culture What are the 5 key elements that are required to promote a positive *reporting culture* 1. ____ : Reports must be confidential and de-identified 2. ____ : agency collecting analysis reports must be separate from the agency responsible for diciplinary action 3. ____ : must be rapid, useful, accessible and intelligible 4. ____ : mechanisms must make it easy for reporters to complete and file 5. ____ : aboveall else, this is vitally important

1. ANONYMITY : Reports must be confidential and de-identified 2. UNBIASED AGENCIES : agency collecting analysis reports must be separate from the agency responsible for diciplinary action 3. FEEDBACK : must be rapid, useful, accessible and intelligible 4. EASE OF REPORTING : mechanisms must make it easy for reporters to complete and file 5. TRUST : aboveall else, this is vitally important ## Footnote 636

# Positive Safety Culture A process by which people can learn from the mistakes and near mistakes of others

FEEDBACK ## Footnote 636

# Positive Safety Culture A cultural dicipline required in order to benefit from the feedback from others mistakes and near mistakes

LEARNING CULTURE ## Footnote 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 ## Footnote 637

# Positive Safety Culture A *just culture* is one in which all members of the organisation ____ the boundary between ____ behaviour

1. KNOW & UNDERSTAND 2. ACCEPTABLE & UNACCEPTABLE ## Footnote 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 ## Footnote 637

# Positive Safety Culture A just culture *IS or IS NOT* a punitive culture in which all errors are punished

IS NOT ## Footnote 637

# Positive Safety Culture What are the 5 cultural elements that make up a positive safety culture [POSITIVE SAFETY CULTURE](https://drive.google.com/file/d/1HnWft5QBskQiUE69RHMAN-Yppm72VqZq/view?usp=drive_link)

1. JUST CULTURE 2. REPORTING CULTURE 3. INFORMED CULTURE 4. LEARNING CULTURE 5. FLEXIBLE CULTURE [COMPLETED](https://drive.google.com/file/d/1EfRKzb_AnsKC1yX9hnpsLe4aycbe3MYH/view?usp=drive_link) ## Footnote 638

# Myth of Safety First What are the 3 elements that make up recurrent accidents

1. UNIVERSAL 2. LOCAL TRAPS 3. DRIVERS ## Footnote 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 ## Footnote 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 ## Footnote 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** ## Footnote 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) ## Footnote 640

# Safety Management System (SMS) An SMS system encompasses what 3 factors

1. TECHNICAL 2. HUMAN 3. ORGANISATIONAL ## Footnote 640