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