failures

Question 1

4 categories of failure causes

Answer 1

aims
organsiations
methods
people

Question 2

aims causes

Answer 2

ill defined goal
not enough detail on requirements
unrealistic

Question 3

organisaztion causes

Answer 3

not enough resources
size
methodology
planning and control 
organiszation

Question 4

methods causes

Answer 4

technical issue

technological failure

Question 5

people

Answer 5

people managment
personality failure
wrong people
user needs

Question 6

who made the swiss cheese model

Answer 6

James REason

Question 7

what did james susggest for the swiss chees modeel

Answer 7

put up more barriers with fewer holes

Question 8

two types of failures

Answer 8

latent- prior , lying fdormant

active, occured at time of failure

Question 9

3 levels of human error

Answer 9

1 skill based error
2 rule based error- routine decision making “if…then..”
3 knowlegde based error-using basic principals to determin way forward

Question 10

skill based error (action slips) ususaly due to ..and some examples

Answer 10

due to inattention /overattention

data-driven error
interruptions
omission-missing out step
repititions- repeating completed step
reversals
undoing completed step

Question 11

rule based error

Answer 11

wrong strong rule
new info , dont change rule
too much info, overlooked critical

Question 12

knowledge based error

Answer 12

selectivity of data
confirmation bias
over confidence
causality

Question 13

error detection needs

Answer 13

feedback mechanism (monitoring)
discrepancy between expected/observed

Question 14

error prevention methjods

Answer 14

training
right environment
well design tools
checklists
simulations
constraints

Question 15

allow for human errors

Answer 15

back up system
limitors
factor of safety 
automate tasks
extra protection

Question 16

all to common

Answer 16

lives depend on tech, shows to be bad under low load, then fails

Question 17

failure lessons 1-8

Answer 17

1 cannot design out failure
2 dont economise on safety
3 cutting edge +prestige bad
4 testing andf checking
5 number 8 wire bnad
6 avoid group thinking 
7 tunel vision
8 culture to bring up issues

Question 18

rickovers seven principals of safe systems

Answer 18

1 commitment to quality
2 capable people
3 supervisors need to listen
4 everyone needs respect for risks
5 training
6  functions given to spcific people, repair etc
7 learn from mistakes