Chapter 15 - Cultural Influences on Error Flashcards
Who is responsible for flight safety?
Everyone
What is the most significant piece of equipment introduced to improve safety and when was it introduced?
Ground Proximity Warning System (GPWS)
1980
The Aviation Authority is an “open culture”. What are the key characteristics of an open culture?
All levels of the organisation play a part in ensuring safety.
Mistakes can be reported without risk of sanction, which allows others to know about them and create preventative measures.
What is a closed culture?
One which an organisation would be reluctant to release information/reports on errors/threats/undesired aircraft states.
What factors promote a good safety culture?
Leadership
Commitment
Setting good examples
What is meant by an error chain?
Errors are cumulative and so subsequent errors can form an error chain. Breaking one link, or highlighting and fixing and error, can break an error chain.
What are the components of a positive safety culture?
A just culture A reporting culture An informed culture A learning culture A flexible culture
What does TEM stand for?
Threat & Error Management
What are the 3 components, with definitions, of Threat & Error management?
Threats - events beyond the influence of the crew
Errors - Actions or inactions by flight crew.
Undesired Aircraft State (UAS) - Crew induced aircraft configuration deviation
How do threats develop into an un-safe outcome?
Threats when undefended become errors.
Errors when uncorrected become a UAS.
A UAS when not handled correctly will become an un-safe outcome.
What is the acronym for the different types of threats and what are they?
LEO
Latent threats - not obvious/unseen, eg. Poor equipment design(unseen), quick turn around times.
Environmental threats - Weather, Terrain, ATC.
Organisational threats - Operations, Documentation Aircraft/cabin design (seen)
What is the acronym for the different types of errors and what are they?
PAC
Procedural errors - Caused by the interaction between a pilot and a procedure, such as an SOP.
Aircraft handling errors - Caused by an interaction between a pilot and the aircraft through various controls.
Communication errors - Caused by an interaction between a pilot and other people such as ATC and ground crew.
What is the acronym for the different types of UAS and what are they?
AGI
Aircraft heading - Vertical and/or lateral and/or speed deviation.
Ground navigation - eg Incorrect taxi holding position or taxiway.
Incorrect system configuration - Wrong automation mode configuration, wrong flap configuration etc.
What is the ATM threat and error management strategy?
Avoid threats
Trap errors
Mitigate UASs
All so that an incident or accident does not occur.
What three things makes up a persons personal competency as a pilot?
KSA
Knowledge - The store of professional knowledge you acquire, enabling you to recognise, understand and deal with new situations.
Skills - Operating and interpersonal skills you need to operate a commercial airliner in a multi-crew environment.
Attitude - Your mental approach to the job and the education and training involved.
What are the 8 core competencies of a pilot?
CAALPAWS
1) Communication
2) Aircraft flight path management (manual)
3) Aircraft flight path management (automatic)
4) Leadership & teamwork
5) Problem solving and decision making
6) Application of procedures
7) Workload management
8) Situational awareness
What can we do to completely avoid human error?
We can’t completely avoid human error. It is inevitable.
What is an informed culture?
Those who manage and operate the system have current knowledge about the human, technical, organisational and environmental factors that determine the safety of the system as a whole.
What is a reporting culture?
An organisation climate in which people are prepared to report their errors and near misses.
What is a just culture?
An atmosphere of trust in which people are encouraged for providing essential safety related information; but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviours.
What is a flexible culture?
A culture in which an organisation is able to reconfigure itself in the face of high tempo operations or certain kinds of danger - often shifting from the conventional hierarchical to flatter mode.
What is a learning culture?
An organisation must possess the willingness and the competence to draw the right conclusions from its safety information system and the will to implement major reforms.
What are the 5 components of the SHELL model?
Software (information)
Hardware (electrical units and equipment)
Environment (weather/atmosphere inside or outside of the cockpit)
Liveware (pilot)
Liveware (other people)
What can cause errors in the liveware to software interaction?
Poorly indexed or unclear information layout/operating documents or odd sequence of drills causing.
What can cause errors in the liveware to environment interaction?
Things like noise, temperature, lighting and weather. More latent things like stress and organisational pressure also come into this category.
What can cause errors in the liveware to hardware interactrion?
Poor ergonomics, such as a 3 point altimeter compared to a digital display.
What is the increased error rate associated with a 3 point altimeter?
It is 3 times more difficult to read and increases error rate by 20%
