9.8 Human Error

Question 1

What types of errors are there?

Answer 1

Design vs Operator
Variable constant
Reversible vs irreversible
Slips, lapses and mistakes

Question 2

What is the shell model?

Answer 2

A model to understand human factors issues.

Question 3

What does SHELL stand for?

Answer 3

Software
Hardware
Environment
Live-ware

Question 4

What are the negative sides of software?

Answer 4

It can be misinterpreted or poorly designed.

Question 5

What are the negative sides of hardware?

Answer 5

Not having enough tools.

Question 6

What are the negatives of Environment?

Answer 6

Uncomfortable workspaces.

Question 7

What are the negatives of live-ware?

Answer 7

Bad relationships with others, poor communication.

Question 8

What is the pear model?

Answer 8

Recalls the four considerations for assessing and mitigating human factors.

Question 9

What are the parts of the pear model?

Answer 9

People
Environment
Actions
Resources

Question 10

What is the error chain?

Answer 10

A series of human factors incidents linking up to cause a bigger issue.

Question 11

Prof. James Reason discusses what two types of human error?

Answer 11

Variable and Constant.

Question 12

What is key about constant errors?

Answer 12

They can be predicted and therefore controlled

Question 13

What is another way to categorise errors?

Answer 13

Determine whether they are reversible or irreversible.

Question 14

What is a slip?

Answer 14

Actions not carried out as planned or intended i.e. steps to a procedure in the wrong order.

Question 15

What are lapses?

Answer 15

Missed actions or ommisions.

Question 16

What is a mistake?

Answer 16

Bought about by faulty planning.

Question 17

What is a violation?

Answer 17

Deliberate actions.

Question 18

What three categories can engineer behaviour be split into?

Answer 18

Skill based
Rule based
Knowledge based

Question 19

What is a skill based behaviour?

Answer 19

Relies on stored routines or motor programmes that have been learned with practice.

Question 20

What is reversion?

Answer 20

Carrying out a procedure they have done for years not knowing it has been revised?

Question 21

What is rule based behaviour?

Answer 21

Routine or procedure has been learnt.

Question 22

What is knowledge based behaviour?

Answer 22

No procedure has been established.

Question 23

What is confirmation bias?

Answer 23

Ignoring evidence to the contrary.

Question 24

What is a latent failure?

Answer 24

Made in the past, yet to be discovered.

Question 25

In relation to visual inspection what is a type 1 error?

Answer 25

Good item incorrectly identified as faulty.

Question 26

In relation to visual inspection what is a type 2 error?

Answer 26

When a fault is overlooked.

Question 27

What are the four types of violation?

Answer 27

Routine Optimising Situational Exceptional.

Question 28

What is a routine violation?

Answer 28

Violation under the influence of a norm.

Question 29

What is a optimising violation?

Answer 29

Breaking the rules for fun.

Question 30

What is a situational violation?

Answer 30

Circumstantial factors, such as time pressure, workload, tooling wtc.

Question 31

What is an exceptional violation?

Answer 31

Involve tasks or operating circumstances where a violation was inevitable.

Question 32

What does MORS stand for?

Answer 32

Mandatory Occurrence Reporting System.

Question 33

What are the basic considerations when deciding if too report?

Answer 33

Did a dangerous situation occur? Could an incident occured? Could it happen in the future?

Question 34

What are MORS?

Answer 34

Safety reports sent to the CAA for analysis and trend monitoring.

Question 35

What CAA publication details the procedures for reporting?

Answer 35

CAP382 MORS

Question 36

What is CHIRP?

Answer 36

Confidential Human Factors Incident Reporting Programme.

Question 37

What are the two components of error management?

Answer 37

Containment and reduction.