9.8 Human Error Flashcards
What types of errors are there?
Design vs Operator
Variable constant
Reversible vs irreversible
Slips, lapses and mistakes
What is the shell model?
A model to understand human factors issues.
What does SHELL stand for?
Software
Hardware
Environment
Live-ware
What are the negative sides of software?
It can be misinterpreted or poorly designed.
What are the negative sides of hardware?
Not having enough tools.
What are the negatives of Environment?
Uncomfortable workspaces.
What are the negatives of live-ware?
Bad relationships with others, poor communication.
What is the pear model?
Recalls the four considerations for assessing and mitigating human factors.
What are the parts of the pear model?
People
Environment
Actions
Resources
What is the error chain?
A series of human factors incidents linking up to cause a bigger issue.
Prof. James Reason discusses what two types of human error?
Variable and Constant.
What is key about constant errors?
They can be predicted and therefore controlled
What is another way to categorise errors?
Determine whether they are reversible or irreversible.
What is a slip?
Actions not carried out as planned or intended i.e. steps to a procedure in the wrong order.
What are lapses?
Missed actions or ommisions.
What is a mistake?
Bought about by faulty planning.
What is a violation?
Deliberate actions.
What three categories can engineer behaviour be split into?
Skill based
Rule based
Knowledge based
What is a skill based behaviour?
Relies on stored routines or motor programmes that have been learned with practice.
What is reversion?
Carrying out a procedure they have done for years not knowing it has been revised?
What is rule based behaviour?
Routine or procedure has been learnt.
What is knowledge based behaviour?
No procedure has been established.
What is confirmation bias?
Ignoring evidence to the contrary.
What is a latent failure?
Made in the past, yet to be discovered.
In relation to visual inspection what is a type 1 error?
Good item incorrectly identified as faulty.
In relation to visual inspection what is a type 2 error?
When a fault is overlooked.
What are the four types of violation?
Routine
Optimising
Situational
Exceptional.
What is a routine violation?
Violation under the influence of a norm.
What is a optimising violation?
Breaking the rules for fun.
What is a situational violation?
Circumstantial factors, such as time pressure, workload, tooling wtc.
What is an exceptional violation?
Involve tasks or operating circumstances where a violation was inevitable.
What does MORS stand for?
Mandatory Occurrence Reporting System.
What are the basic considerations when deciding if too report?
Did a dangerous situation occur?
Could an incident occured?
Could it happen in the future?
What are MORS?
Safety reports sent to the CAA for analysis and trend monitoring.
What CAA publication details the procedures for reporting?
CAP382 MORS
What is CHIRP?
Confidential Human Factors Incident Reporting Programme.
What are the two components of error management?
Containment and reduction.
