9.8 Flashcards
What is the SHELL model
Software : documents, manuals
Hardware: tools, equipment
Environment: includes the physical environment such and hanger condition and work environment such a pattern and management structure
Live-ware: interaction between two or more people.
What size the paer model
People
Environment
Actions
Resources
What is the error chain
Management
Maintenance
Crew- team work
Flight safety
In one part of the change brakes the will be compromised flight safety
What is the Swiss cheese model
If all the holes in the Swiss cheese line up there will be an accident.
Many faliers happen in a sequence thing may go rong.
What is violation
It is a deliberate or illegal action which someone does which the know is against the rules
What is a slip
It is where actions are not carried out as intended or planed.
These take place in the execution stage
What is a lapses
It is a missed action. Forgetting something Due to memory.
What is a Mistake
Made during the planing stage. Someone doing something they thought was correct but is not.
What is the difference between a verryable and constant error
Routine violations
When someone get complacent.
Optimising violation
Breaking the rules for fun. Unrelated to the actual task
Seen as an opertuninty to satisfy a personal need
Situational violation
These are down to circumstantial factors. This can be down to time pressure, high work load, unworkable procedures, inadequate tooling
Exceptional violations
Tasks where violation is inevitable
What is a type 1 error
Error happens when a good item Is incorrectly identified as faulty
Not a safety concern by definition
What is a type 2 error
Type 2 is when a fault is overlooked.
Undetected fault leads to serious conciquenses
