9.8 Human error Flashcards
What does SHELL model stand for
Software, Hardware, Environment, Live-ware
What does PEAR model stand for
People, Environment, Actions, Resources
Explain the ‘Swiss Cheese Model’ approach
aims to reduce the chances of human error by implementing more safeguards
Explain the ‘Error chain’
Accidents that involved a series of human factor problems . (Preventative measures should have been implemented earlier to break the chain)
What are ‘slips’
- Actions which were not carried out as intended or planned
- Occur during task execution
What are ‘Lapses’
- Missed actions and omissions
- Occur at storage (memory) stage
What are ‘Mistakes’
- error caused by a faulty plan or intention
- Occur at planning stage
What are ‘violations’
- deliberate ‘illegal’ actions
Explain what constant errors are
- Follow a certain consistent , systematic pattern
- Can be predicted
Explain what variable errors are
- Cannot be forseen and are much harder to manage
What is a type 1 error
- When a good item is incorrectly identified as faulty
What is a type 2 error
- When a fault is overlooked
What is a routine violation
- Practices that have become ‘the normal way of doing something’
- e.g. cutting corners to save time
What are optimising violations
- Breaking the rules for fun
What are exceptional violations
- Tasks or operating circumstances where violations are inevitable
What are situational violations
- Down to circumstantial factors such as time pressure, high workload, unworkable procedures, inadequate tooling, poor working conditions etc.
Errors that do not cause accidents, but still cause a problem are known as?
Incidents
What is the confidential human factors incident reporting programme (CHIRP)
- Can report safety concerns and incidents confidentially
What is the aim of error management
- prevent errors from occurring
- eliminate or mitigate the impact of errors
What is Mandatory occurence reporting system (MORS)
all maintenance incidents must be reported to UK CAA via MORS
