2105 Flashcards
the state in which the possibility of harm to persons or of the property damage is reduced to, and
maintained at or below, an acceptable level through a continuing process of hazard identification and safety risk
management
safety
dynamic characteristic of the aviation system, whereby safety risks must be continuously mitigated
safety
years of the technical era
from the early 1900s until the late 1960s
Aviation emerged as a form of mass transportation in which identified safety deficiencies were initially related to technical factors and technological failures.
technical era
technological improvements led to a gradual decline in the frequency of accidents, and safety processes were broadened to encompass regulatory compliance and oversight.
technical era
years of the human factors era
from the early 1970s until the mid-1990s
the frequency of
aviation accidents was significantly reduced due to major technological advances and enhancements to safety
regulations.
human factors era
years of the organizational era
from the mid-1990s to the present day
from the mid-1990s to the present day
organizational era
Who developed the Swiss-Cheese Model
Professor James Reason
illustrates that accidents involve successive
breaches of multiple system defenses
Swiss-Cheese Model
contends that complex systems such as aviation are extremely well defended by layers of defences, single-point failures are rarely consequential in such systems.
Swiss-Cheese Model
can be a delayed consequence of decisions made at the highest levels of the system, which may remain dormant until their effects or damaging potential are activated by specific operational circumstances
breaches in safety defenses
are actions or inactions, including errors and violations, which have an immediate adverse effect.
active failures
are those that exist in the aviation system well before a damaging outcome is experienced.
latent conditions
have all the potential to breach aviation system defenses
latent conditions
defences in aviation can
be grouped under three large headings:
technology, training, regulations
are largely intuitive in that all those with operational experience have experienced them to varying degrees, and include workforce stability, qualifications and experience, morale, management credibility, and traditional ergonomics factors such as lighting, heating and cooling.
workplace conditions
A simple yet visually powerful conceptual tool for the analysis of the components, the features of operational
contexts and the possible interactions with people is the
SHEL(L) Model
can be used to help visualize the interrelationships among the various components and features of the aviation system
SHEL(L) Model
4 components of SHEL(L) Model
Software, Hardware, Environment, Liveware
procedures, training, support
Software
machine and equipment
Hardware
the working environment in which the rest of the L-H-S system must function
Environment
humans in the workplace
Liveware
In the centre of the SHELL model are the humans at the front line of operations. Although humans are remarkably adaptable, they are subject to considerable variations in performance.
Liveware
refers to the relationship between the human and the
physical attributes of equipment, machines and facilities
Liveware-Hardware
is the relationship between the human and the supporting systems found in the workplace, e.g. regulations, manuals, checklists, publications, standard operating procedures (SOPs) and computer software.
Liveware-Software
is the relationship among persons in the work environment. Since flight crews, air traffic controllers, aircraft maintenance engineers and other
operational personnel function in groups, it is important to recognize that communication and interpersonal skills, as well as group dynamics, play a role in determining human performance.
Liveware-Liveware
This interface involves the relationship between the human and both the internal and external environments.
Liveware-Environment
a mismatch between the Liveware and the other four components contributes
to human error.
SHELL Model
An action or inaction by an operational person that leads to deviations from organizational or the operational person’s intentions or expectation
Error
are failures in the execution of the intended action
Slips and Lapses
are actions that do not
go as planned
slips
memory failures
lapses
failures in the plan of action
mistakes
assume the error will be made
capturing strategies
provide direct intervention to reduce or eliminate the factors contributing to the error.
reduction strategies
the intent is to capture the error before any adverse consequences of the error are felt
capturing strategies
that they utilize checklists and other procedural interventions
rather than directly eliminating the error.
capturing strategies
refer to the ability of a system to accept that an error will be made but without experiencing serious consequences.
tolerance strategies
a deliberate act of willful misconduct or omission resulting in a deviation from established regulations, procedures, norms, or practices
violation
three types of violations
situational violation, routine violation, organizationally induced violation
committed in response to factors experienced in a specific context, such as time pressure or high workload.
situational violation
Such violations are committed in response to situations in which compliance with established procedures makes task completion difficult.
routine violations
This type of violation tends to occur when an organization attempts to meet increased output demands by ignoring or stretching its safety defenses
organizationally induced violations
