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2105 | Aviation Safety > Finals > Flashcards

Finals Flashcards

1
Q

Twelve primary contributing factors that cause human errors and affect human performance.

A

Dirty Dozen

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2
Q

Human factors that degrade people’s ability to perform effectively and safely which could lead to maintenance errors.

A

Dirty Dozen

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3
Q

Were adopted by the aviation industry as a straightforward means to discuss human error in maintenance.

A

Dirty Dozen

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4
Q

Maintenance-related aviation accidents occurred during what years?

A

Late 1980s and early 1990s

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5
Q

Who identified twelve human factors?

A

Transport Canada

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6
Q

Identified by Transport Canada

A

12 Human factors

Dirty Dozen

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7
Q

Dirty Dozen:

Failure to transmit, receive or provide enough information to complete a task.

A

Lack of Communication

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8
Q

Dirty Dozen:
Only 30% of verbal communication is received and understood by either side in a conversation. Others usually remember the first and last part of what you say.

A

Lack of Communication

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9
Q

Dirty Dozen:

Overconfidence from repeated experience performing a task.

A

Complacency

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10
Q

Dirty Dozen:

Shortage of the training, information, and/or ability to successfully perform.

A

Lack of Knowledge

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11
Q

Dirty Dozen:

Avoidance of being a know-it-all

A

Lack of Knowledge

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12
Q

Dirty Dozen:

Anything that draws your attention away from the task at hand.

A

Distraction

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13
Q

Dirty Dozen:

The #1 cause of forgetting things, including what has or has not been done in a maintenance task.

A

Distraction

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14
Q

Dirty Dozen:

Safety net: always use or refer to your checklist, go back 3 steps when proceeding after distraction.

A

Distraction

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15
Q

Dirty Dozen:

Failure to work together to complete a shared goal.

A

Lack of Teamwork

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16
Q

Dirty Dozen:

Lack of communication can occur.

A

Lack of Teamwork

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17
Q

Dirty Dozen:

Physical or mental exhaustion threatens work performance.

A

Fatigue

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18
Q

Dirty Dozen:

Not having enough people, equipment, documentation, time, parts, etc. to complete a task.

A

Lack of Resources

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19
Q

Dirty Dozen:

Real or perceived forces demanding high-level job performance.

A

Pressure

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20
Q

Dirty Dozen:

Failure to speak up or document concerts about instructions, orders, or the actions of others.

A

Lack of Assertiveness

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21
Q

Dirty Dozen:

A physical, chemical, or emotional factor that causes physical or mental tension

A

Stress

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22
Q

Dirty Dozen:

Safety net: take a break when needed, do not stress yourself more.

A

Stress

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23
Q

Dirty Dozen:

Happens with a lack of alertness

A

Lack of Awareness

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24
Q

Dirty Dozen:

Failure to recognize a situation, understand what it is, and predict the possible results.

A

Lack of Awareness

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25
Q

Dirty Dozen:

Expected, yet unwritten, rules of behavior.

A

Norms

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26
Q

Dirty Dozen:

Inevitable to be adapted.

A

Norms

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27
Q

Dirty Dozen:

Safety net: stick to the regulations and proper procedures.

A

Norms

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28
Q

MEDA meaning

A

Maintenance Error Decision Aid

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29
Q

A structured process that is used to investigate events caused by maintenance technician and/or inspector performance.

A

Maintenance Error Decision Aid (MEDA)

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30
Q

Its purpose is to gather the information that is needed to carry out an event investigation.

A

Maintenance Error Decision Aid (MEDA)

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31
Q

It is an interview with the maintenance technician and/or inspector whose performance led to the event.

A

MEDA Event Investigation

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32
Q

MEDA Event Investigation finds out: (2)

A
  1. What errors and violations occurred

2. The contributing factors to the errors and violations

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33
Q

From error model to ____ model

A

Event

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34
Q

“ERROR” investigation process to “___” investigation

A

EVENT

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35
Q

“___” investigation process to “EVENT” investigation

A

ERROR

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36
Q

Errors/Violations that are committed by the technician.

A

Events

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37
Q

Not all events are caused by ___.

A

Errors

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38
Q

Not all ___ are caused by errors.

A

Events

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39
Q

Anything that contributes to committing events

A

Contributing Factors

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40
Q

Can negatively affect how a maintenance technician and/or inspector does his/her job

A

Contributing Factors

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41
Q

Ranges from the smallest of things to critical decision making

A

Contributing Factors

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42
Q

MEDA Event Model 2

A

Initial MEDA Error Model

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43
Q

MEDA Event Model 3

A

Probabilistic MEDA Error Model

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44
Q

MEDA Event Model 4

A

Enhanced MEDA Error Model

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45
Q

MEDA Event Model 5

A

Further Enhanced MEDA Error Model

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46
Q

MEDA Event Model 6

A

Event Model 1 with Violation Leading Directly to a System Failure

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47
Q

MEDA Event Model 7

A

Event Model 2 with a Violation Causing the Technician Not to Catch an Error-Caused System Failure

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48
Q

MEDA Event Model 8

A

Combined Violation Model

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49
Q

MEDA Event Model 9

A

Final MEDA Event Model

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50
Q

Explained using the final MEDA event model

A

MEDA Philosophy

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51
Q

A maintenance-related event can be caused by an error, by a violation, or by an error/violation combination

A

MEDA Philosophy

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52
Q

Maintenance errors are not made on purpose

A

MEDA Philosophy

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53
Q

Maintenance errors are caused by a series of contributing factors

A

MEDA Philosophy

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54
Q

Violations, while intentional, are also caused by contributing factors

A

MEDA Philosophy

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55
Q

Most of these errors or violations contributing factors are under the control of management, therefore, can be improved so that they do not contribute to future, similar events.

A

MEDA Philosophy

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56
Q

Developed by Boeing in 1992

A

MEDA

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57
Q

Used to help address errors and eventually even violations

A

MEDA Investigation Process

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58
Q

MEDA Investigation Process:

1.

A

Event Occurs

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59
Q

MEDA Investigation Process:

2.

A

Investigation find that event was caused by technician/inspector performance

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60
Q

MEDA Investigation Process:

3.

A

Find the maintenance technician/inspector who did the work

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61
Q

MEDA Investigation Process:

4.

A

Interview the person

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62
Q

MEDA Investigation Process:

4. Objectives in interviewing the person

A
  1. Find error/violations
  2. Find contributing factors
  3. Get ideas for process improvement
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63
Q

MEDA Investigation Process:

5. __ to get all relevant contributing factors information

A

Carry out follow-up interview

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64
Q

MEDA Investigation Process:

6. ___ to a maintenance event database

A

Add the result from investigation information

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65
Q

MEDA Investigation Process:

7.

A

Make process improvements

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66
Q

MEDA Investigation Process:

7. Make process improvements based on:

A
  1. This event

2. Data from multiple events

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67
Q

MEDA Investigation Process:

8. ___ affected by the process improvements

A

Provide feedback to all employees

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68
Q

Accurate and timely reporting of relevant information related to hazards, incidents, or accidents is a fundamental activity of safety management.

A

Safety Reporting

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69
Q

The data used to support safety analyses are reported by multiple sources.

A

Safety Reporting

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70
Q

One of the best sources of data is direct reporting from?

A

Front-line personnel

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71
Q

Prerequisite for effective safety reporting

A

Personnel have been:

  1. Trained
  2. Encouraged to report errors and experiences
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72
Q

Things, situations, activities, or conditions can bring harm and can cause lives.

A

Hazard

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73
Q

Identifying ___ is one way to prevent ___

A
  1. Hazard

2. Accidents

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74
Q

Safety Management is caused by _____

A

Safety Hazard Reporting

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75
Q

_____ is caused by Safety Hazard Reporting

A

Safety Management

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76
Q

To prevent hazards

A

Reporting hazards

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77
Q

Through safety hazard reporting the management will be able to:

A
  1. Identify the hazard

2. Improve safety

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78
Q

Five Basic Characteristics of Effective Safety Reporting

A
  1. Willingness
  2. Information
  3. Flexibility
  4. Learning
  5. Accountability
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79
Q

Characteristic:

People are willing to report their errors and experiences

A

Willingness

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80
Q

Characteristic:

Management should be a culture of willingness

A

Willingness

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81
Q

Characteristic:

Related to communication and trust between the employees and the management.

A

Willingness

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82
Q

Characteristic:

People are knowledgeable about the human, technical, and organizational factors that determine the safety of the system.

A

Information

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83
Q

Characteristic:

Trained to report the proper risks.

A

Information

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84
Q

Characteristic:

Knowledgeable enough to know if a certain event is already a hazard.

A

Information

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85
Q

Characteristic:

Because you have a realistic view of the hazard you know the damage.

A

Information

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86
Q

Characteristic:

People can adapt reporting when facing unusual circumstances, shifting from the established mode to a direct mode.

A

Flexibility

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87
Q

Characteristic:

Allowing information to quickly reach the appropriate decision-making level.

A

Flexibility

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88
Q

Characteristic:

People have the competence to draw conclusions from safety information systems.

A

Learning

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89
Q

Characteristic:

The will to implement major reforms.

A

Learning

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90
Q

Characteristic:

People are encouraged and rewarded for providing essential safety-related information.

A

Accountability

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91
Q

Characteristic:

There is a clear line that differentiates between acceptable and unacceptable behavior.

A

Accountability

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92
Q

Types of Reporting

A
  1. Online reporting
  2. Hotline reporting
  3. Verbal reporting
  4. Hard copy reporting
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93
Q

Organizational literature proposes three characterizations of organizations, depending on how they respond to information on hazards and safety information management.

A

Westrum Organizational Culture

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94
Q

Westrum Organizational Culture is created by?

A

Ron Westrum

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95
Q

What did Ron Westrum invent?

A

Westrum Organizational Culture

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96
Q

Three characterizations of organizations:

A
  1. Pathological
  2. Bureaucratic
  3. Generative
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97
Q

Westrum:

Hides the information.

A

Pathological

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98
Q

Westrum:

Power-oriented

A

Pathological

99
Q

Westrum:

Restrains the information

A

Bureaucratic

100
Q

Westrum:

Rule-oriented

A

Bureaucratic

101
Q

Westrum:

Many factors must be considered that’s why the process is slow phased.

A

Bureaucratic

102
Q

Westrum:

Values the information.

A

Generative

103
Q

Westrum:

Goal-oriented

A

Generative

104
Q

___ is characterized by the beliefs, values, biases, and their resultant behavior that are shared among members of safety, group, or organization.

A

Culture

105
Q

Set of values, behaviors, and attitudes

A

Culture

106
Q

Encouraging or giving confidence to the employees to report hazards.

A

Safety Culture

107
Q

One of those nebulous things, like safety management.

A

Safety Culture

108
Q

Behavior and performance of employees when no one is watching.

A

Safety Culture

109
Q

You cannot see it or touch it. You can only see evidence or absence of its existence.

A

Safety Culture

110
Q

It is not something you get or buy; it develops over time and must be maintained.

A

Safety Culture

111
Q

Relies on a high degree of trust and respect between personnel and management and must therefore be created and supported at the senior management level.

A

Positive Safety Culture

112
Q

Like trust, ____ takes time and effort to establish and can be easily lost.

A

Positive Safety Culture

113
Q

Created by Patrick Hudson

A

Safety Culture Maturity Model

114
Q

Developed back in 2000s (2003)

A

Safety Culture Maturity Model

115
Q

The model specifies at which level the hazard is.

A

Safety Culture Maturity Model

116
Q

The model which is increasingly informed

A

Safety Culture Maturity Model

117
Q

The model which is increasing in trust and accountability

A

Safety Culture Maturity Model

118
Q

Five-step progression of Safety Culture Maturity Model

A
  1. Pathological
  2. Reactive
  3. Calculative
  4. Proactive
  5. Generative
119
Q

Maturity Model:

Who cares as long as we are not caught?

A

Pathological

120
Q

Maturity Model:

No care safety culture

A

Pathological

121
Q

Maturity Model:

“Who cares” approach

A

Pathological

122
Q

Maturity Model:

Business is top priority

A

Pathological

123
Q

Maturity Model:

Also known as emerging

A

Pathological

124
Q

Maturity Model:

Safety is important, we do a lot every time we have an accident

A

Reactive

125
Q

Maturity Model:

Safety is regarded as a burden

A

Reactive

126
Q

Maturity Model:

Fix to blame approach

A

Reactive

127
Q

Maturity Model:

They see accidents are caused by employees

A

Reactive

128
Q

Maturity Model:

Also known as managing

A

Reactive

129
Q

Maturity Model:

There are systems in place to manage all hazards

A

Calculative

130
Q

Maturity Model:

Many audits are collective which will be used to improve the system.

A

Calculative

131
Q

Maturity Model:

The mindset of the management is the system they have is already enough.

A

Calculative

132
Q

Maturity Model:

Complacency

A

Calculative

133
Q

Maturity Model:

Everything is cased by what happened in the past

A

Calculative

134
Q

Maturity Model:

Safety is not the core value

A

Calculative

135
Q

Maturity Model:

Also known as involving

A

Calculative

136
Q

Maturity Model:

Safety leadership and values drive continuous improvement.

A

Proactive

137
Q

Maturity Model:

They aim to anticipate the problems before it happens.

A

Proactive

138
Q

Maturity Model:

They consider factors that might go wrong in the future

A

Proactive

139
Q

Maturity Model:

They act before future mistakes may happen.

A

Proactive

140
Q

Maturity Model:

Safety is top priority

A

Proactive

141
Q

Maturity Model:

They use bad news to further improve the system.

A

Proactive

142
Q

Maturity Model:

Safety is the core value

A

Proactive

143
Q

Maturity Model:

Also known as cooperating

A

Proactive

144
Q

Maturity Model:

Generate High-Reliability Organization (HRO), Health, Safety, and Environment (HSE)

A

Generative

145
Q

Maturity Model:

That is how we do business around here.

A

Generative

146
Q

Maturity Model:

They use failure to improve, not to blame

A

Generative

147
Q

Maturity Model:

Never think that their system is never enough.

A

Generative

148
Q

Maturity Model:

Despite all their efforts, they believe that accidents may and will occur.

A

Generative

149
Q

Maturity Model:

Safety environment is a top priority. (Core Value)

A

Generative

150
Q

Maturity Model:

Safety is not driven by numbers, but by a core value that safety is an integral part of the operation.

A

Generative

151
Q

Maturity Model:

Safety improvement is investment, not a cost

A

Generative

152
Q

Maturity Model:

They have outstanding communication with their workforce.

A

Generative

153
Q

Maturity Model:

Also known as continually improving

A

Generative

154
Q

If “A” exists, then “B” will occur.

A

Cause-In-Fact

155
Q

If “A” exists, the the the probability of “b” occurring increases.

A

Probabilistic

156
Q

There are few “cause-in-fact” occurrences in the ____ world

A

Maintenance technician/inspector’s

157
Q

MEDA Event Model:
Figure 1:
Contributing factors -> error:
Almost all causes are

A

Probabilistic

158
Q

MEDA Event Model:
Figure 1:
Error -> event:
it is possible to have some

A

Cause-In-Fact

159
Q

MEDA Event Model:
Figure 3:
There is a probabilistic relationship between:

A
  1. Contributing factors and an error

2. An error and an event

160
Q

MEDA Event Model:

Figure 4: There are ___ contributing factors to each error

A

3 to 5

161
Q

MEDA Event Model:

Figure 5: There are ____ to the contributing factors

A

Contributing factors

162
Q

MEDA Event Model:
Figure 5:
Ask why how many times?

A

5 times

163
Q

MEDA Event Model:

Two ways that a violation can contribute to an event

A

Figure 6 and 7

164
Q

MEDA Event Model:
Figure 6:
The maintenance technician does not use a torque wrench when called out in the maintenance manual

A

Violation

165
Q

MEDA Event Model:
Figure 6:
He under torques the bolt

A

System Failure

166
Q

MEDA Event Model:
Figure 6:
Air turn back

A

Event

167
Q 
MEDA Event Model: 
Figure 6:
Reasons for not using torque wrench:
- There was no torque wrench
- Work norm to not use a torque
A

Contributing factors

168
Q

MEDA Event Model:
Figure 7:
Failure to carry out an operational check

A

Violation

169
Q

MEDA Event Model:
Figure 7:
Failure to carry out an operational check at the ___ of the procedure would catch an error.

A

End

170
Q

MEDA Event Model:

If the technician failed and then the inspector failed the system an event will occur

A

Figure 8: Combined Violation Model

171
Q

MEDA Event Model:

Summarization of causational events

A

Figure 9: Final MEDA Event Model

172
Q

MEDA Event Model:

Interprets the theoretical bases of MEDA

A

Figure 9: Final MEDA Event Model

173
Q

MEDA Event Model:

Final event causation model that includes errors and violations

A

Figure 9: Final MEDA Event Model

174
Q

MEDA was developed by?

A

Boeing

175
Q

When was MEDA developed?

A

1992

176
Q

The potential outcome of the hazard.

A

Consequence

177
Q

A potential source of damage.

A

Hazard

178
Q

Projected likelihood and severity of the consequences or outcome from an existing hazard or situation.

A

Safety Risk

179
Q

While the outcome may be an accident, intermediate unsafe event/consequences may be identified as – the most credible outcome.

A

Safety Risk

180
Q

Addresses, analyses, and mitigates all risks.

A

Risk Management

181
Q

Reduces the hazard at an acceptable level/

A

Risk Management

182
Q

The likelihood of how often an unsafe event might occur.

A

Safety Risk Probability

183
Q

One way to determine the probability of hazards.

A

Records

184
Q

How many people are likely to get involved with this hazard.

A

Safety Risk Probability

185
Q

Probability:

Likely to occur many times

A

Frequent

186
Q

Probability:

Has occurred frequently

A

Frequent

187
Q

Probability:

Value of 5

A

Frequent

188
Q

Probability:

Likely to occur sometimes

A

Occasional

189
Q

Probability:

Has occurred infrequently

A

Occasional

190
Q

Probability:

Value of 4

A

Occasional

191
Q

Probability:

Unlikely to occur, but possible

A

Remote

192
Q

Probability:

Has occurred rarely

A

Remote

193
Q

Probability:

Value of 3

A

Remote

194
Q

Probability:

Very unlikely to occur

A

Improbable

195
Q

Probability:

Not known to have occurred

A

Improbable

196
Q

Probability:

Value of 2

A

Improbable

197
Q

Probability:

Almost inconceivable that the event will occur

A

Extremely Improbable

198
Q

Probability:

Value of 1

A

Extremely Improbable

199
Q

After knowing the probability, you must then assess or identify the ___

A

Safety Risk Severity

200
Q

The extent of harm that might reasonably occur as a consequence or outcome of the identified hazard.

A

Safety Risk Severity

201
Q

The extent of the damage

A

Safety Risk Severity

202
Q

The extend of the hazard

A

Safety Risk Severity

203
Q

The environmental impact which can be identified using questions.

A

Safety Risk Severity

204
Q

Severity:

Equipment destroyed

A

Catastrophic

205
Q

Severity:

Multiple deaths

A

Catastrophic

206
Q

Severity:

Value of A

A

Catastrophic

207
Q

Severity:
A large reduction is safety margins, physical distress, or a workload such that the operators cannot be relied upon to perform their tasks accurately or completely.

A

Hazardous

208
Q

Severity:

Serious injury

A

Hazardous

209
Q

Severity:

Major equipment damage

A

Hazardous

210
Q

Severity:

Value of B

A

Hazardous

211
Q

Severity:
A significant reduction in safety margins, a reduction in the ability of the operators to cope with adverse operating conditions because of an increase in workload or because of condition impairing their efficiency.

A

Major

212
Q

Severity:

Serious incident

A

Major

213
Q

Severity:

Injury to persons

A

Major

214
Q

Severity:

Value of C

A

Major

215
Q

Severity:

Nuisance

A

Minor

216
Q

Severity:

Operating limitations

A

Minor

217
Q

Severity:

Use of emergency procedures

A

Minor

218
Q

Severity:

Minor incident

A

Minor

219
Q

Severity:

Value of D

A

Minor

220
Q

Severity:

Few consequences

A

Negligible

221
Q

Severity:

Value of E

A

Negligible

222
Q

Also known as Safety Risk Index or Risk Index

A

Safety Risk Assessment Matrix

223
Q

Combination of the result of the probability and the assessment of the severity of the hazard.

A

Safety Risk Assessment Matrix

224
Q

Safety Risk Tolerability Matrix:

3 Regions:

A
  • Intolerable region
  • Tolerable region
  • Acceptable region
225
Q

Tolerability Matrix:

High-risk

A

Intolerable

226
Q

Tolerability Matrix:

Unacceptable under any circumstances

A

Intolerable

227
Q

Tolerability Matrix:

The probability and/or severity of the consequences and the damaging potential of the hazard is a threat to safety.

A

Intolerable

228
Q

Tolerability Matrix:

Immediate mitigation is required

A

Intolerable

229
Q

Tolerability Matrix:

The risk is unacceptable at any level

A

Intolerable

230
Q

Tolerability Matrix:

The risk is acceptable but further analysis is required.

A

Tolerable

231
Q

Tolerability Matrix:

Medium risk

A

Tolerable

232
Q

Tolerability Matrix:

Acceptable provided that acceptable mitigation strategies are implemented.

A

Tolerable

233
Q

Tolerability Matrix:

Low risk

A

Acceptable

234
Q

Tolerability Matrix:

The risk is acceptable as it currently stands.

A

Acceptable

235
Q

Tolerability Matrix:

Acceptable as they currently stand.

A

Acceptable

236
Q

Overall Management

A

Safety Risk Management

237
Q

The assessment and mitigation of safety risks.

A

Safety Risk Management

238
Q

It assesses the risks associated with the identified hazards.

A

Safety Risk Management

239
Q

Develops and implements effective and appropriate mitigations.

A

Safety Risk Management

240
Q

A key component of the safety management process at both the State and product/service provider level.

A

Safety Risk Management

241
Q

HIRA meaning

A

Hazard Identification Risk Assessment

242
Q

Probability:

5 Safety Risk Probability

A
  • Frequent
  • Occasional
  • Remote
  • Improbable
  • Extremely Improbable
243
Q

Severity:

5 Safety Risk Severity

A
  • Catastrophic
  • Hazardous
  • Major
  • Minor
  • Negligible
244
Q

pinaka cute niyong kaklase?

A

si pau, sino pa ba?!?!?!

2105 | Aviation Safety (3 decks)

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