9.8 Human Error - Types Of Error To Avoiding And Managing Errors

Question 1

what 2 forms of errors take place in aircraft engineering?

Answer 1

1. error that results in a specific aircraft problem that was not there before. (ie. install wrong LRU)
2. an error that results in an unwanted or unsafe condition remaining undetected whilst performing maintenance (structural crack missed during inspection)

Question 2

what errors may occur with regular maintenance tasks?

Answer 2

not keeping up with changes to frequently used procedures

Question 3

what are routine tasks prone to? (3)

Answer 3

complacency, environmental capture and rule-based errors

Question 4

what errors may occurs with maintenance tasks that are less frequently carried out?

Answer 4

errors of judgements
non-familiarisation with the task,
wrong selection of spares and procedures

Question 5

what 4 types of violations is there?

Answer 5

-routine
-optimising
-situational
-exceptional

Question 6

what is routine violations?

Answer 6

are things which have become “the normal way of doing something”

ie, not replacing o-rings

Question 7

what are optimising viloations?

Answer 7

involve breaking the rules for “kicks”
often unrelated to the task
opportunity to satisfy personal need

Question 8

what are situational violations?

Answer 8

errors that occur at the time

Ie. time pressure, workload, procedures, tooling and working conditions

trying to get the job done, not following procedures

Question 9

what are exceptional violations?

Answer 9

tasks or operating circumstances that make violations inevitable

Question 10

why are principles and habits bad and errors occur from it?

Answer 10

as they become the rule of thumb but may not work in every aspect but are still applied (boring vs airbus)

Question 11

what are the 2 types of errors associated with visual inspections?

Answer 11

1. occurs when a good item is identified as faulty (resource wasted looking for nothing)
2. occurs when a faulty item is missed (ie damage)

Question 12

how are errors and accidents linked?

Answer 12

by the iceberg

the visible part of the iceberg is the major/serious accidents
non visible part, operational incident and unreported incident resulting in no harm or minor injuries

Question 13

however big or small an incident may be, what has to happen and why?

Answer 13

MOR’s

to help shape the safety of the aviation industry

Question 14

what CAP is used for MOR’s?

Answer 14

cap 382

Question 15

what is CHIRP?

Answer 15

confidential human factors incident reporting programme

Question 16

what does CHIRP do?

Answer 16

reporting mechanism for individuals who want to report safety concerns and incidents confidentially

Question 17

what is the most important aspect of errors?

Answer 17

is that you learn from them and others

Question 18

what is a just culutre?

Answer 18

where engineers are encouraged to speak up if they have made an error.

Question 19

what may a just culture lead to?

Answer 19

an engineer covering up their errors and discouraging them to come clean about them

Question 20

what does error management seek to do?

Answer 20

1. prevent errors from occurring
2. eliminate or mitigate the bad effects of errors

Question 21

what are the 2 components of error management?

Answer 21

1. error containment
2. error reduction

Question 22

within an organisation, how is error management implemented?

Answer 22

by using a safety management system to capture data on errors, incidents and accidents, identify potential weak spots and guide training and new defences

Question 23

what is the one thing most likely to prevent errors?

Answer 23

ensuring engineers follow procedures

Question 24

what error managment measures could be used?

Answer 24

-minimise error liability
-reduce error vulnerability
-discover, assess and eliminate error-producing factors
-diagnose organisation factors
-enhance error detection
-increase error tolerance
-make latent conditions more visible
-improve the organisation’s intrinsic resistance to human fallibility