2. Accidents. & Errors.

Question 1

Norman - routine vios

Answer 1

when it is so often it is ignored. ex.: routine shortcuts = vio of procedure

Question 2

Norman - situational vios

Answer 2

vio under special circumstances. ex.: drive fast because you need to get something

Question 3

Norman - slips

Answer 3

when someone intends to perform one action, but performs another

Question 4

Norman - action-based slips

Answer 4

wrong action is performed. ex: put milk in coffee then put coffee cup in fridge instead of milk -> didn’t mean to do that

Question 5

Norman - memory-lapse slips

Answer 5

intended action is not performed or the results are not evaluated. ex.: forget to turn off gas stove/forget locking door. -> i forgot

Question 6

Norman - mistakes

Answer 6

wrong goal is set or wrong plan is formed

Question 7

Norman - rule-based mistakes

Answer 7

good diagnosis of situation, followed wrong rules to base the action. ex.: choosing incorrect procedure/failure to identify risk -> that was the wrong choice

Question 8

Norman - knowledge based mistakes

Answer 8

wrong diagnosis of problem due to incomplete knowledge. ex.: weighing something in pounds instead of kgs. -> i did not know what i was doing was wrong

Question 9

Norman - memory-lapse mistakes

Answer 9

when something is forgotten in the goals, plans or evaluation stages. ex.: when mechanic can’t complete everything because he is distracted/skipping step in procedure because you’re doing 2 things at once.

Question 10

Norman - capture slips

Answer 10

situation where, instead of action, a more frequent action is performed: it records the activity. ex.: leave house and walk to school instead of supermarket

Question 11

Norman - description similarity slips

Answer 11

error is to respond to an item that is similar to target. ex.: pouring oj in cereal/putting wrong lid on bowl

Question 12

Norman - memory-lapse slips

Answer 12

immediate cause are interruptions. ex.: forgetting phone/driving with coffee cup on top of the car

Question 13

Norman - mode-error slip

Answer 13

when a device has different states/modes, causing control to have different meanings. ex.: When an electric guitar is turned off by a switch, if you don’t turn the switch back on, the electric guitar will have a diff sound

Question 14

Norman - skill-based mistakes

Answer 14

occurs when workers are extremely expert at their jobs, so they can do the everyday routine tasks with little or no thought or conscious attention.
More of a slip

Question 15

Norman - rule-based mistakes

Answer 15

Diagnose the situation but decide to take the wrong action, (wrong rule is followed)
Eg. go to change your clothes, instead of putting clothes to go out you put on your pj’s

Question 16

Norman - knowledge-based mistakes

Answer 16

occur when unfamiliar events occur, where neither existing skills nor rules apply.
Eg. weighing of fuel computed in pounds instead of kgs

Question 17

Norman - memory-lapse mistakes

Answer 17

mistakes due to memory failure to forget goal/plan; due to interruption.
when there is forgetting in-between stages of goals
Disturbe sequence of the action (diff than slips) → happens in higher levels

Question 18

Norman - design lessons from errors

Answer 18

adding constraints to block errors, undo, confirmation and error messages, make item more prominent, make operation reversible, sensibility checks, minimizing steps

Question 19

Norman - swiss cheese model

Answer 19

Each slice of cheese represents a condition in the task that needs to be done, an accident can only happen if holes in all the slices of cheese are exactly on the same line. Therefore, it is difficult to look for “the cause” of an accident because it has been preceded by several exactly matching errors. Several ways to reduce accidents are:

• Ensuring more slices of cheese; thus, more defenses;
• Reducing the number of gaps by, for example, better equipment;
• Alerting operators when several holes line up.

Question 20

Reason - person approach

Answer 20

focus on unsafe acts of people. cause: forgetfulness, inattention, poor motivation etc. just world hypothesis

Question 21

Reason - system approach

Answer 21

humans are fallible and errors can be expected. error is consequences with origin in systemic factors.

Question 22

Reason - swiss cheese model

Answer 22

Defenses, barriers, and safeguards occupy a key position in the system approach. o The function is to protect potential victims and assets from local hazards. Most do that effectively, but there are always weaknesses.
• In an ideal world, each defensive layer would be intact. However, they are more like slices of
Swiss cheeses, having many holes. The presence of wholes does not normally cause a bad outcome. Only when the
holes in multiple layers line up at the same time to allow an accident trajectory can
this happen. Active failures = unsafe acts committed by people who are in direct contact with the patient or system.
▪ Direct and short-lived impact on the integrity of defenses.
▪ At Chernobyl, for example, the operators wrongly violated plant procedures
and switched off successive safety systems, thus creating the immediate
trigger for the catastrophic explosion in the core.
▪ Followers of the person approach often look no further for the causes of an adverse event once they have identified these proximal unsafe acts
Latent condition = arise from decisions made by designers, builders procedure writes, and top-level management.
▪ Inevitable resident pathogens (virus) within the system.
▪ May be latent for years within the system before combining with active
failures and local triggers to create an accident opportunity.
• Unlike active failures, which can take a variety of forms that are
difficult to predict, latent circumstances can be detected and corrected before a negative event happens. This knowledge leads to proactive risk management rather than reactive risk management.
• Latent conditions have two kinds of adverse effects:
o They can translate into error provoking conditions within the local workplace; time
pressure, understaffing, inadequate equipment, fatigue, inexperience
o They can create long-lasting holes or weaknesses in the defenses; untrustworthy
alarms and indicators, unworkable procedures design, and construction deficiencies

Question 23

Reason - error management

Answer 23

Error management has two components:
o Limiting the incidence of dangerous errors;
o Creating systems that are better able to tolerate the occurrence of errors and
contain their damaging effects.
• High-reliability organizations – systems operating in hazardous conditions that have fewer
than their fair share of adverse events – offer important models for what constitutes a resilient system.
o Has intrinsic safety health: is able to withstand its operational dangers and yet still achieve its objective.

Question 24

Day - goal study

Answer 24

study relationship between level of cognitive failure and individual, psychological stress and workplace accidents

Question 25

Day - results H1

Answer 25

people in accident group more stress + more psychological strain. & higher reported cognitive failure. so, individuals with an accident in the navy have high levels of psychological stress and daily failure.

Question 26

Day - results H2

Answer 26

people who score high on levels of psychological stress (ghq) are more prone to an accidents, cognitive functioning mediates this. high scores on daily failure task, so fail a lot are the processes by which high stress determines whether or not there is an accident. so, elevated stress = probably more accidents because prone to cognitive errors.

Question 27

Day - conclusion

Answer 27

high cfq scores indicates increased vulnerability when work demands are high. those with psychological stress more likely to have an accident because of increased susceptibility to cognitive errors. best to hire stress-resistant people and lower work demands

Question 28

Hansen - introversion and extroversion

Answer 28

intro: less accidents, more control
extro: more accidents and safety vios.

Question 29

Hansen - assumptions about accidents

Answer 29

1. determinants of accidents are multiple, only a part attributable to personality. 2. number of personality trait, some unrelated to another, related to accidents. 3. people rarely repeat accidents.

Question 30

Hansen - locus of control

Answer 30

external: more involved in accidents
internal: actively try to prevent accidents

Question 31

Hansen - aggression

Answer 31

part of a set of traits consistently associated with accidents

Question 32

Hansen - social maladjustment

Answer 32

combination of behaviors is often found and associated with high accidents rate. (sociopaths attitudes, immaturity, irresponsiblity etc.)

Question 33

Hansen - neurosis

Answer 33

social maladjustment more distressing because person’s attention is diverted from task, neurosis correlated with accidents. + multidimensional, only some parts related to accidents: depression, guilt and anxiety

Question 34

Hansen - impulsivity

Answer 34

more reckless and more accidents

Question 35

Hansen - taking risks

Answer 35

experiences workers, older workers and female workers take fewer risks than inexperienced, young, male workers.

Question 36

Hansen - conclusion

Answer 36

o There is much evidence that locus of control is related to accidents, especially external locus
of control.
o Extraversion is strongly related to high accident rates.
o Aggression is strongly and repeatedly associated with accidents.
o There is much evidence that social maladjustment is not only related to incidents but is
probably a primary factor in accident causation.
o There appears to be an association between general neurosis and accidents.
o Specific neurotic disorders such as anxiety and depression have ( in the few studies on these
topics) been associated with accidents.
o There is consistent and reasonably strong evidence to link impulsivity to accidents. o The research is too thin to conclude anything about risk-taking and accidents.

Question 37

Christian - goal study

Answer 37

personal and situational antecedents of safety performance and safety outcomes

Question 38

Christian - person-related proximate antecedents

Answer 38

safety knowledge and safety motivation: willingness to make an effort to perform safety behaviors

Question 39

Christian - person related distal antecedents

Answer 39

conscientiousness: more trustworthy, neuroticism, extraversion, locus of control, propensity for risk taking, job attitudes

Question 40

Christian - situation related distal antecedents

Answer 40

psychological safety climate: individual perception of policies and group-level safety climate: shared perception work environment and leadership

Question 41

Christian - results proximal person-related factors

Answer 41

safety performance strong with safety knowledge & motivation. safety motivation strong with compliance.

Question 42

Christian - results distal person related factors

Answer 42

partial support safety performance (moderate to locus of control, weakly to C). job attitudes weakly to safety performance (support). locus of control stronger with safety participation (support). partial support for C, N, locus of control and job attitudes weakly to safety outcomes.

Question 43

Christian - distal situation related factors

Answer 43

support overall safety climate and performance. leadership relationship with safety performance supported; strong with safety participation than with compliance and average relation with safety performance + weak with accidents. psychological climate more to participation same for leadership. leadership weakly to safety outcomes. FIGURE.

Question 44

Christian - model

Answer 44

all direct paths were significant, so support for full mediation model. support for the framework.

Question 45

Christian - conclusion

Answer 45

Safety climate was positively related to both safety knowledge and safety motivation, whereas conscientiousness was positively associated with just safety motivation. Safety motivation was related to safety knowledge, and both of these variables were positively related with safety performance.
→Safety performance was correlated with accidents and injuries.

Question 46

Christian - results

Answer 46

• Proximal variables are higher correlated than distal variables: this is true for safety performance but not for safety outcomes.
• In general, evidence for the model was found.
• Safety climate is positively related to safety knowledge and to safety motivation.
• Conscientiousness is only positively related to safety motivation.
  Safety motivation is related to safety knowledge and both are positively related to safety performance.
• Safety performance is negatively correlated with accidents and injuries. The following figures show the results found:
  • Safety knowledge and safety motivation exhibited stronger effects for the safety performance than any of the distal factors.
  • No support for safety outcomes
  o Distal factors had stronger magnitudes than the proximal factor safety knowledge.

Question 47

Frese - error management perspective

Answer 47

pointless to prevent all errors from occuring. add-on strategy. through design, training, prevention works by blocking erroneous. starts after error occurred and attempts to block negative error consequences

Question 48

Frese - avoiding or reducing negative error consequences

Answer 48

reducing changes or error cascade: one error leading to the next. systems damage control, organizations’ and teams’ damage control. damage control within the social realm: re-establishing trust and gaining forgiveness

Question 49

Frese - positive outcomes of error management

Answer 49

learning from errors. emotional processes associated with learning from errors. motivational processes associated with learning from errors: intrinsic motivation and learning goal orientation. cognitive processes and behavioral activities associated with learning from errors. learning from errors with minor versus major negative consequences

Question 50

Frese - negative outcome bias

Answer 50

more attention is paid to and more learning is instigated by events with more negative outcomes.

Question 51

Error management and performance

Answer 51

Error management training leads to learning and improved performance.