18. Strategies for Coping with Human Error Flashcards
Strategies for coping with human error
Zero defect programmes are conceptually STRONG or FLAWED
FLAWED
- They are formed on the belief that human error can be eradicated
- Human errors however are considered as being inevitable
1
Strategies for coping with human error
A less radical approach to coping with human error than the zero defect programme is what
ERROR CAUSE REMOVAL
(ECR)
1
Strategies for coping with human error
Which of the following tasks are better suited to a human;
[ ] Inductive reasoning
[ ] Monitoring
[ ] Deductive reasoning
[ ] Intelligence
[ ] Speed
[ ] Error correction
[ ] Power
[ ] Consistency
[ ] Complex activities
[ ] Short term memory
[ ] Computation
[X] ** Inductive reasoning
[ ] Monitoring
[ ] Deductive reasoning
[X] Intelligence
[ ] Speed
[X**] Error correction
[ ] Power
[ ] Consistency
[ ] Complex activities
[ ] Short term memory
[ ] Computation
Strategies for coping with human error
Which of the following tasks are better suited to a machine;
[ ] Inductive reasoning
[ ] Monitoring
[ ] Deductive reasoning
[ ] Intelligence
[ ] Speed
[ ] Error correction
[ ] Power
[ ] Consistency
[ ] Complex activities
[ ] Short term memory
[ ] Computation
[ ] Inductive reasoning
[X] Monitoring
[X] Deductive reasoning
[ ] Intelligence
[X] Speed
[ ] Error correction
[X] Power
[X] Consistency
[X] Complex activities
[X] Short term memory
[X] Computation
Strategies for coping with human error
- A system that is set up so that the conseuqences of an error will not jeopardise safety is said to be what
- A system where a single error can cause a disaster is said to be what
- TOLERANT TO ERROR
- VULNERABLE TO ERROR
3
Strategies for coping with human error
Emphasis is placed on training, re-training and performance checking as this forms part of which learning technique which is identified as being very effective
OVER LEARNING
- Recall from the learning chapter than over learning is a technique used to aid with long term memory recall
3
Strategies for coping with human error
“The scratch pad system on flight management computers allows pilots to check their entry before committing it to the system”
This is an example of what type of strategy for reducing the consequences of error
REVERSIBLE ERRORS
3
Strategies for coping with human error
“A system that is designed to physically prevent errors being made. An example being the weight on wheels switch which prevents undercarriages from being selected up whilst the aircraft is on the ground”
This is an example of what type of strategy for reducing the consequences of error
ERROR PREVENTION
3
Strategies for coping with human error
“A long established method of two crew members cross checking”
This is an example of what type of strategy for reducing the consequences of error
CROSS MONITORING
3
Strategies for coping with human error
“A system incorporated to monitor human performance and to warn when dangerous situations are developing. For example, ground proximity warning systems”
This is an example of what type of strategy for reducing the consequences of error
MACHINE MONITORING SYSTEMS
3
Strategies for coping with human error
What are the 3 components that make up the TEM model
- THREAT
- ERROR
- UNDESIRED AIRCRAFT STATE
4
Strategies for coping with human error
“Events or errors that occur beyond the influence of the flight crew, which increase operational complexity, and which must be managed to maintain the margins of safety”
This is a definition of which component within the TEM model
THREAT
- Threats are defined as events that occur beyond the influence of the flight crew
- Threats may be anticipated, unexpected, or latent
4
620
Strategies for coping with human error
“Actions or inactions by the flight crew that lead to deviations from organisational or flight crew intentions or expectations”
This is a definition of which component within the TEM model
ERROR
4
620
Strategies for coping with human error
“Any crew-induced position or speed deviations, misapplication or flight controls, or incorrect ssytems configuration, which causes a reduction in safety margins”
This is a definition of which component within the TEM model
UNDESIRED AIRCRAFT STATE
4
620
Strategies for coping with human error
Threats may arise in what 3 forms;
[ ] Anticipated
[ ] Delayed
[ ] Unexpected
[ ] Latent
[ ] Sudden
[ ] Startled
[X] Anticipated
[ ] Delayed
[X] Unexpected
[X] Latent
[ ] Sudden
[ ] Startled
- Anticipated - flight crew know that thunderstorms are forecast in vacinity of aerodrome
- Unexpected - sudden in flight malfunction or navigation aid un-servicibility
- Latent - threats not directly obvious
5
Strategies for coping with human error
- Flight crew knowing that a thunderstorm is forecast in the vacinity of the aerodrome is an example of a ANTICIPCATED or UNEXPECTED or LATENT threat
- Sudden in flight malfunction of navigation aid un-servicibility is an example of a ANTICIPCATED or UNEXPECTED or LATENT threat
- Threats that are not directly obvious is an example of a ANTICIPCATED or UNEXPECTED or LATENT threat
- ANTICIPATED
- UNEXPECTED
- LATENT
5
Strategies for coping with human error
Threats, which can be anticipated, unepxected or latent, can be further sub-divided into 2 categories;
[ ] Expected
[ ] Beyond mitigation
[ ] Environmental
[ ] Organisational
[ ] Health and Safety
[ ] Expected
[ ] Beyond mitigation
[X] Environmental
[X] Organisational
[ ] Health and Safety
- Note that environmental does not necessarily exclusively mean weather
- For example, an environment could be a situation we find ourselves in i.e. the operational environment
- An approach where suddenly the runway in use is changed is an environmental threat as you find yourself in a given situation that now increases workload which was beyond your control
- An unservicable navigiation aid (ie. on the ground) may seem like an organisational threat. As a deep dive, it could be if the failure were due to bad maintenance practices, but on the surface, the aid being unavailable is considered an environmental threat as it is assumed otherwise it would be working and assisting the pilot, who now finds themselves in a situation where it is unavailable to them.
5
Strategies for coping with human error
Identify the following threats and marry them up to whether they are environmental or organisational, as well as identifying their sub category i.e. weather, or airport, or terrain etc.
- Heavy turbulence [ ] [ ]
- Cross/tail winds on landing [ ] [ ]
- Poor ATC commands [ ] [ ]
- Conflicting callsigns on comms [ ] [ ]
- Complex taxi/ramp procedures [ ] [ ]
- Short runway [ ] [ ]
- Runway on a slope [ ] [ ]
- High ground [ ] [ ]
- Aircraft malfunction [ ] [ ]
- Cabin event [ ] [ ]
- Cabin door security [ ] [ ]
- De-icing issues [ ] [ ]
- Dispatch error [ ] [ ]
- Documentational error [ ] [ ]
- Late arrival [ ] [ ]
- Delays [ ] [ ]
- Heavy turbulence [ENVIRONMENTAL] [WEATHER]
- Cross/tail winds on landing [ENVIRONMENTAL] [WEATHER]
- Poor ATC commands [ENVIRONMENTAL] [ATC]
- Conflicting callsigns on comms [ENVIRONMENTAL] [ATC]
- Complex taxi/ramp procedures [ENVIRONMENTAL] [AIRPORT]
- Short runway [ENVIRONMENTAL] [AIRPORT]
- Runway on a slope [ENVIRONMENTAL] [TERRAIN]
- High ground [ENVIRONMENTAL] [TERRAIN]
- Aircraft malfunction [ORGANISATIONAL] [AIRCRAFT]
- Cabin event [ORGANISATIONAL] [CABIN]
- Cabin door security [ORGANISATIONAL] [CABIN]
- De-icing issues [ORGANISATIONAL] [GROUND CREW]
- Dispatch error [ORGANISATIONAL] [DISPATCH/SCHEDULING]
- Documentational error [ORGANISATIONAL] [DISPATCH/SCHEDULING]
- Late arrival [ENVIRONMENTAL] [OPERATIONAL PRESSURE]
- Delays [ENVIRONMENTAL] [OPERATIONAL PRESSURE]
5/6/7
Strategies for coping with human error
Errors in the TEM model fall into what 3 categories;
[ ] Misinterpretation
[ ] Aircraft handling
[ ] Procedural
[ ] Slips
[ ] Communications
[ ] Mistakes
[ ] Misinterpretation
[X] Aircraft handling
[X] Procedural
[ ] Slips
[X] Communications
[ ] Mistakes
8
Strategies for coping with human error
“Caused by an interaction between the pilot and the aircraft through various controls”
This is an example of which type of error category
[ ] Aircraft handling
[ ] Procedural
[ ] Communications
[X] Aircraft handling
[ ] Procedural
[ ] Communications
8
Strategies for coping with human error
“caused by the interaction between a pilot and a checklist or SOP”
This is an example of whcih type of error category
[ ] Aircraft handling
[ ] Procedural
[ ] Communications
[ ] Aircraft handling
[X] Procedural
[ ] Communications
8
Strategies for coping with human error
“caused by the interaction between the pilot and other people such as ATC or ground crew”
This is an example of whcih type of error category
[ ] Aircraft handling
[ ] Procedural
[ ] Communications
[ ] Aircraft handling
[ ] Procedural
[X] Communications
8
Strategies for coping with human error
Undesired aircraft states, if poorly managed, can lead to further errors, escalating the situation. This could possibly lead into what 2 outcomes
- ACCIDENT
- INCIDENT
11
Strategies for coping with human error
Undesired aircraft states are broken down into what 3 basic categories;
[ ] Unstable conditions
[ ] Aircraft Handling
[ ] Ground Navigation
[ ] Laternal Navigation
[ ] Incorrect aircraft configuration
[ ] Excessively high cost index
[ ] Unstable conditions
[X] Aircraft Handling
[X] Ground Navigation
[ ] Laternal Navigation
[X] Incorrect aircraft configuration
[ ] Excessively high cost index
11
Strategies for coping with human error
A flight crew selects a wrong approach in the Flight Management Computer (FMC). The flight crew subsequenclty identifies the error during a cross check prior tot he Final Approach Fix (FAF).
- Scenario 1: Both crew get fixed into trying to re-programme the FMC and as a result, the aircraft flies high through the localiser, descending late and causing an unstable approach. This is an example of ERROR MANAGEMENT or UNDESIRED AIRCRAFT STATE MANAGEMENT
- Scenario 2: Instead of getting fixed into trying to re-program the FMC, the flight crew use basic mode i.e. heading, and manually fly the desired track. This is an example of ERROR MANAGEMENT or UNDESIRED AIRCRAFT STATE MANAGEMENT
- ERROR MANAGEMENT
- UNDESIRED AIRCRAFT STATE MANAGEMENT
- The TEM model assists in educating flight crews that when the aircraft is in an undeisred state, the basic task is undesired aircraft state management and not to get locked in on error management
- In scenario 1, getting locked into error management escalated the situation, putting the aircraft off of the localiser and into an unstable dangerous approach
- In scenario 2, the crew understand the sitaution but rather than getting distracted, focus on the current situation and effectively manage it to maintain safety.
12
Strategies for coping with human error
What is the term used for the measurement of the human body when designing flight decks and considering the ergonomics;
[ ] Anthropromorphic
[ ] Anthrobipedal
[ ] Anthrostatic
[ ] Anthropometry
[ ] Anthropromorphic
[ ] Anthrobipedal
[ ] Anthrostatic
[X] Anthropometry
13
Strategies for coping with human error
Flight decks are designed in such a way that the pilot should adapt to the ergonomics of the design TRUE or FALSE
FALSE
- Cockpits are designed to fit the pilot, not the other way around
13
Strategies for coping with human error
Flight deck crew seats must be fully adjustable and include ____ support to push the spine into a comfortable shape
LUMBAR SUPPORT
- ensures compression loads on the discs are evenly spread
14
Strategies for coping with human error
The point that becomes the reference for all other aspects of the cockpit layout including the reach distance to controls and control panels is based around what point
EYE DATUM REFERENCE POINT
- It is assumed that the pilot will adjust their seating position to ensure their eyes are positioned at the datum point
15
Strategies for coping with human error
Cockpit instrument layouts should be what in order to provide consistency and reduce the liklihood of increased error as a result of different layouts
STANDARDISED
16
Strategies for coping with human error
A MULTI-POINTER or DIGITAL AND POINTER altimeter is slower to read and likely to give rise to errors in misinterpretation
MULTI-POINTER
18
Strategies for coping with human error
The design of controls is important in trying to minimise operationally induced errors and to bring standardisation.
- The “ON” position of a switch is always UP or DOWN
- The “ON” position of a switch is ALWAYS or NEVER relative to the pilots viewpoint
- UP
- ALWAYS
19
Strategies for coping with human error
Refer to the following diagram.
A pilot who has been used to flying with a fuel selector with the “BOTH” in the forward position transfers to an aircraft that has the “OFF” selector in the forward position and accidently selects it.
This is an example of what
HABIT REVERSION
(Negative Habit Transfer)
20
Strategies for coping with human error
Care and attention is given to the design and layout of checklists;
- Excessive use of uppercase characters reduces what
- Use of colour on checklists IS or IS NOT a good design feature
- Logical and unambigious indexing systems are essental. PAGE & PARAGRAPH NUMBERING or LETTERING is more easily recognisable
- How is complex information better represented
- READABILITY
- IS NOT (should be minimised)
- PAGE & PARAGRAPH NUMBERING
- DIAGRAMS and CHARTS
- Red colour on check lists can be washed out by the infared colour of the cockpit lighting
21
Strategies for coping with human error
The overriding principle of a warning system design is that it shuld be what
ATTENTION GETTING
22
Strategies for coping with human error
Warning systems server what 2 main functions’
[ ] Alert
[ ] Stimulate
[ ] Startle
[ ] Increase adrenaline
[ ] Inform
[X] Alert
[ ] Stimulate
[ ] Startle
[ ] Increase adrenaline
[X] Inform
22
Strategies for coping with human error
The field of human-machine interface (HMI) is goal orientated. The main goals are;
[ ] Cost saving
[ ] As few as possible
[ ] Safety
[ ] Humanisation compatibility
[ ] Environmental compatibility
[ ] Obvious
[ ] Productivity (economics)
[ ] Cost saving
[ ] As few as possible
[X] Safety
[X] Humanisation compatibility
[X] Environmental compatibility
[ ] Obvious
[X] Productivity (economics)
23
Strategies for coping with human error
“Important controls are always placed within easy reach. Controls used in a particular order are position in such a way that the order is logical. Controls used simultaneously are grouped together i.e. throttles”
This is the definition of what design principle
POSITIONING AND SEQUENCING
23
Strategies for coping with human error
“Controls are made to look and feel different to make it easier to distinguish between them i.e. the flap lever looks like a flap, the gear lever looks like a wheel”
This is the definition of what design principle
IDENTIFICATION OF CONTROLS
23
Strategies for coping with human error
“Displays and controls are positioned to reflect their relationship in a logical fashion. i.e. left throttle and engine information is on the left, right for the right etc..”
This is the definition of what design principle
SPATIAL RELATIONSHIP
23
Strategies for coping with human error
A design principle that is used to protect switches and levers to induce thought proceess before activiation
GUARDS and INTERLOCKS
24
Strategies for coping with human error
The countermeasures utilized in TEM can be split into what 2 major categories
- HARD RESOURCES (systemic based)
- SOFT RESOURCES (personal/team tactics and strategies)
- Hard resource countermeasures are also known as “systemtic based”.
- They are referred to as systemic as they are embedded into the aviation system i.e. Legislation controls, aircraft systems, operational procedures, crew training
- Soft resource countermeasures are direct human (crew) input
25
Strategies for coping with human error
The countermeasures utilized in TEM can be split into hard resources and soft resources. Soft resources (direct human input) can be sub divided into what 3 types;
[ ] Planning countermeasures
[ ] Execution countermeasures
[ ] Functional countermeasures
[ ] Review countermeasures
[ ] Logical countermeasures
[X] Planning countermeasures
[X] Execution countermeasures
[ ] Functional countermeasures
[X] Review countermeasures
[ ] Logical countermeasures
25
Strategies for coping with human error
“includes SOP briefing, stated plans, assignment of workloads and contingency management”
This is an example of what soft resource sub category countermeasure
PLANNING COUNTERMEASURE
25
Strategies for coping with human error
“automation and workload management, monitoring and cross checking to help detect errors and properly respond to them”
This is an example of what soft resource sub category countermeasure
EXECUTION COUNTERMEASURE
25
Strategies for coping with human error
“open questioning, evlation and modication of plans coupled with crew assertiveness to effectively manage the ever changing flight conditions”
This is an example of what soft resource sub category countermeasure
REVIEW COUNTERMEASURE
25
Strategies for coping with human error
Decision making is a knowledge-based behaviour and is influenced by a variety of factors including poor or incomplete knowledge or incorrect weighting given to information. A typical decision making process includes what 9 stages;
[ ] Definition of the aim
[ ] Set goal
[ ] Collection of information
[ ] Risk assessment
[ ] Risk mitigation
[ ] Development of options
[ ] Evlation of options
[ ] Decision
[ ] Timely exection
[ ] Implementation
[ ] Consequences
[ ] Result
[ ] Review and feedback
[X] Definition of the aim
[ ] Set goal
[X] Collection of information
[X] Risk assessment
[ ] Risk mitigation
[X] Development of options
[X] Evlation of options
[X] Decision
[ ] Timely exection
[X] Implementation
[X] Consequences
[ ] Result
[X] Review and feedback
26
Strategies for coping with human error
On a flight deck, a pilot will conduct a risk assessment in a decision making situation based upon which 4 basic elements;
[ ] The pilot
[ ] Upset to passengers or cargo
[ ] The aircraft
[ ] Economic (cost)
[ ] Environmental conditions
[ ] Available time
[X] The pilot
[ ] Upset to passengers or cargo
[X] The aircraft
[ ] Economic (cost)
[X] Environmental conditions
[X] Available time
27
Strategies for coping with human error
In a decision making situation a pilot can have clouded judgement when under stress. The basic stressors on a pilot are;
[ ] Physical
[ ] Time
[ ] Physiological
[ ] Psychological
[ ] Workload
[ ] Sociological
[X] Physical
[ ] Time
[X] Physiological
[X] Psychological
[ ] Workload
[X] Sociological
27
Strategies for coping with human error
In a decision making process, a pilot can bring both positive and negative attributes. What are the 3 positive attributes
- CREATIVITY
- INNOVATIVITY
- ADAPTABILITY
27
Strategies for coping with human error
In a decision making process, a pilot can bring both positive and negative attributes. What are the 3 negative attributes
- FALSE MENTAL MODEL
- INCORRECT MOTOR PROGRAMME
- LACK OF FEEDBACK
27
Strategies for coping with human error
Errors can occur at any of the nine stages of the decision making process. Gary Klein (1993) identified 3 main sources;
- Lack of ____
- Lack of ____
- Inadequate ____
- EXPEREINCE
- INFORMATION
- SIMULATION
- A lack of experience leaves the pilot with nothing to base their decision upon
- A lack of information meants that the decision maker does not have enough information to base an informed decision on
- Inadequate simulation is where the potential outcomes of various options have not been adequately considered - the “what ifs”
28
Strategies for coping with human error
An individuals resposne and accuracy of that response to a decision making situation will be determined by who we are, how we are (personality, motivation, attitude), and what is going on around us. Decision making errors are made more likely by which elements;
[ ] Stress
[ ] Time pressure
[ ] Safety conscious
[ ] Distraction
[ ] Focused / Concentrating
[ ] Peer pressure
[ ] Over thinking
[ ] Economic pressure
[ ] Self-imposed pressure
[ ] Determination
[X] Stress
[X] Time pressure
[ ] Safety conscious
[X] Distraction
[ ] Focused / Concentrating
[X] Peer pressure
[ ] Over thinking
[X] Economic pressure
[X] Self-imposed pressure
[ ] Determination
29
