9.8 - Human Errors Flashcards
What models and theories are used to illustrate human error
- SHELL Model
- PEAR Model
- The Error Chain
- The Swiss Cheese Model
What is the SHELL model
- Software
- Hardware
- Environment
- Live-ware (Others, You)
What is software in the SHELL Model
This includes maintenance procedures, maintenance manuals, and check lists
What is the PEAR Model
- People
- Environment
- Actions
- Resources
What type of failures can the Swiss Cheese model prevent
Latent errors
What is the error chain
Some incidents involve several individuals. Anyone of them could have changed the course of events by reacting or querying a particular action
What are the types or errors in maintenance tasks
- Slips
- Lapses
- Mistakes
- Violation
What is a slip
Actions which were not carried out as intended or planned
What’s is a Lapse
Missed actions or omissions
What is a mistake
A specific type of error caused by a faulty plan or intention
What is a violation
They appear to be human errors but are caused deliberately by
What is a design induced error
A design flaw
What is an operator error
Flawed procedures
How does a variable error differ from a constant error
Variable errors are random in nature where as constant errors follow systematic pattern
How can an engineers behaviour be broken down
- Skill based
- Rule based
- Knowledge based
What are Examples of skill based behavioural errors
- Action Slips
- Environmental Capture
- Reversion
What is Reversion
Acquiring a certain pattern of behaviour, which can be very difficult to abandon or unlearn when it’s no longer necessary
What are the types of error used in the context of visual inspection
Type 1 and Type 2
What is type 1 error
When a good item is incorrectly identified as faulty
What is a type 2 error
When a fault is overlooked
What are the four types of violations in aircraft maintenance
- Routine
- Optimising
- Situational
- Exceptional
Where are routine violations
Practices that have become the norm
What are Optimising Violations
Entails breaking the rules for fun or personal gain, usually unrelated to the actual task
What are situational Violations
These are down to circumstantial factors
What are Exceptional Violations
They involve tasks or operating circumstances where violations are inevitable
How are incidents collected and exchanged to prevent aircraft accidents
Mandatory Occurrence Reporting System (MORS)
What are the basic considerations when deciding whether or not to report an incident
- Did a dangerous situation occur
- Could a dangerous situation occur if circumstances been different
- Could a dangerous incident occur if not corrected
How can you report safety concerns and incidents confidentially in the UK
Confidential Human factors Incident Reporting Program (CHIRPS)
How does the maintenance engineering industry manage errors
Organisations must have their own Safety Management System (SMS)
