9.8 Human Error - Types Of Error To Avoiding And Managing Errors Flashcards
what 2 forms of errors take place in aircraft engineering?
- error that results in a specific aircraft problem that was not there before. (ie. install wrong LRU)
- an error that results in an unwanted or unsafe condition remaining undetected whilst performing maintenance (structural crack missed during inspection)
what errors may occur with regular maintenance tasks?
not keeping up with changes to frequently used procedures
what are routine tasks prone to? (3)
complacency, environmental capture and rule-based errors
what errors may occurs with maintenance tasks that are less frequently carried out?
errors of judgements
non-familiarisation with the task,
wrong selection of spares and procedures
what 4 types of violations is there?
-routine
-optimising
-situational
-exceptional
what is routine violations?
are things which have become “the normal way of doing something”
ie, not replacing o-rings
what are optimising viloations?
involve breaking the rules for “kicks”
often unrelated to the task
opportunity to satisfy personal need
what are situational violations?
errors that occur at the time
Ie. time pressure, workload, procedures, tooling and working conditions
trying to get the job done, not following procedures
what are exceptional violations?
tasks or operating circumstances that make violations inevitable
why are principles and habits bad and errors occur from it?
as they become the rule of thumb but may not work in every aspect but are still applied (boring vs airbus)
what are the 2 types of errors associated with visual inspections?
- occurs when a good item is identified as faulty (resource wasted looking for nothing)
- occurs when a faulty item is missed (ie damage)
how are errors and accidents linked?
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
however big or small an incident may be, what has to happen and why?
MOR’s
to help shape the safety of the aviation industry
what CAP is used for MOR’s?
cap 382
what is CHIRP?
confidential human factors incident reporting programme
what does CHIRP do?
reporting mechanism for individuals who want to report safety concerns and incidents confidentially
what is the most important aspect of errors?
is that you learn from them and others
what is a just culutre?
where engineers are encouraged to speak up if they have made an error.
what may a just culture lead to?
an engineer covering up their errors and discouraging them to come clean about them
what does error management seek to do?
- prevent errors from occurring
- eliminate or mitigate the bad effects of errors
what are the 2 components of error management?
- error containment
- error reduction
within an organisation, how is error management implemented?
by using a safety management system to capture data on errors, incidents and accidents, identify potential weak spots and guide training and new defences
what is the one thing most likely to prevent errors?
ensuring engineers follow procedures
what error managment measures could be used?
-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
