9.8 Flashcards
Name the models
SHELL model
PEAR model
Error chain
Swiss cheese model
SHELL model,what does it stand for
Software, Hardware, Environment, Live-ware (others), Live-ware (you)
What does live-ware mean
Describes human factors, the people in the workplace
PEAR model, what does it stand for?
People
Environment
Actions
Resources
What is the error chain model
All incidents could have been avoided if something was done differently.
Describes the chain of events that lead to an accident taking place
What is the Swiss cheese model
Idea of putting safeguards in place
The more holes in a systems defence the more likely something will go wrong
Types of errors in maintenance tasks
Slips, lapses, mistakes ; and violations
What does a slip mean?
Actions that are not carried out as intended or planned
What does “lapses” mean
Missed actions and omissions
Eg failing to do something due to a lapse in memory
What does a “mistake” mean in maintenance errors
Faulty plan/ intentions
What does “violation” refer to
Appear to be human errors but are deliberate ‘illegal’ actions. ‘Cutting corners’
List Other types of errors in maintenance
Design vs operator - induced errors
Variable vs constant errors
Reversible vs irreversible errors
Skill based behaviours and associated errors
Rule based behaviours and associated errors
Knowledge based behaviours and associated errors
Examples of errors in maintenance tasks
Errors during regular and less frequent maintenance tasks
Complacency, environmental capture, and rule based factors
Errors due to individual practices and habits
Errors associated with visual inspection
Errors associated with visual inspection
Type 1 errors
Good item is thought to be faulty
Type 2 error
Defective item is missed
Violations in aircraft maintenance
Routine - they become normal
Optimising - breaking the rule for fun
Situational - down to circumstantial factors
Exceptional - where violations are inevitable
