Finals Flashcards
Twelve primary contributing factors that cause human errors and affect human performance.
Dirty Dozen
Human factors that degrade people’s ability to perform effectively and safely which could lead to maintenance errors.
Dirty Dozen
Were adopted by the aviation industry as a straightforward means to discuss human error in maintenance.
Dirty Dozen
Maintenance-related aviation accidents occurred during what years?
Late 1980s and early 1990s
Who identified twelve human factors?
Transport Canada
Identified by Transport Canada
12 Human factors
Dirty Dozen
Dirty Dozen:
Failure to transmit, receive or provide enough information to complete a task.
Lack of Communication
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.
Lack of Communication
Dirty Dozen:
Overconfidence from repeated experience performing a task.
Complacency
Dirty Dozen:
Shortage of the training, information, and/or ability to successfully perform.
Lack of Knowledge
Dirty Dozen:
Avoidance of being a know-it-all
Lack of Knowledge
Dirty Dozen:
Anything that draws your attention away from the task at hand.
Distraction
Dirty Dozen:
The #1 cause of forgetting things, including what has or has not been done in a maintenance task.
Distraction
Dirty Dozen:
Safety net: always use or refer to your checklist, go back 3 steps when proceeding after distraction.
Distraction
Dirty Dozen:
Failure to work together to complete a shared goal.
Lack of Teamwork
Dirty Dozen:
Lack of communication can occur.
Lack of Teamwork
Dirty Dozen:
Physical or mental exhaustion threatens work performance.
Fatigue
Dirty Dozen:
Not having enough people, equipment, documentation, time, parts, etc. to complete a task.
Lack of Resources
Dirty Dozen:
Real or perceived forces demanding high-level job performance.
Pressure
Dirty Dozen:
Failure to speak up or document concerts about instructions, orders, or the actions of others.
Lack of Assertiveness
Dirty Dozen:
A physical, chemical, or emotional factor that causes physical or mental tension
Stress
Dirty Dozen:
Safety net: take a break when needed, do not stress yourself more.
Stress
Dirty Dozen:
Happens with a lack of alertness
Lack of Awareness
Dirty Dozen:
Failure to recognize a situation, understand what it is, and predict the possible results.
Lack of Awareness
Dirty Dozen:
Expected, yet unwritten, rules of behavior.
Norms
Dirty Dozen:
Inevitable to be adapted.
Norms
Dirty Dozen:
Safety net: stick to the regulations and proper procedures.
Norms
MEDA meaning
Maintenance Error Decision Aid
A structured process that is used to investigate events caused by maintenance technician and/or inspector performance.
Maintenance Error Decision Aid (MEDA)
Its purpose is to gather the information that is needed to carry out an event investigation.
Maintenance Error Decision Aid (MEDA)
It is an interview with the maintenance technician and/or inspector whose performance led to the event.
MEDA Event Investigation
MEDA Event Investigation finds out: (2)
- What errors and violations occurred
2. The contributing factors to the errors and violations
From error model to ____ model
Event
“ERROR” investigation process to “___” investigation
EVENT
“___” investigation process to “EVENT” investigation
ERROR
Errors/Violations that are committed by the technician.
Events
Not all events are caused by ___.
Errors
Not all ___ are caused by errors.
Events
Anything that contributes to committing events
Contributing Factors
Can negatively affect how a maintenance technician and/or inspector does his/her job
Contributing Factors
Ranges from the smallest of things to critical decision making
Contributing Factors
MEDA Event Model 2
Initial MEDA Error Model
MEDA Event Model 3
Probabilistic MEDA Error Model
MEDA Event Model 4
Enhanced MEDA Error Model
MEDA Event Model 5
Further Enhanced MEDA Error Model
MEDA Event Model 6
Event Model 1 with Violation Leading Directly to a System Failure
MEDA Event Model 7
Event Model 2 with a Violation Causing the Technician Not to Catch an Error-Caused System Failure
MEDA Event Model 8
Combined Violation Model
MEDA Event Model 9
Final MEDA Event Model
Explained using the final MEDA event model
MEDA Philosophy
A maintenance-related event can be caused by an error, by a violation, or by an error/violation combination
MEDA Philosophy
Maintenance errors are not made on purpose
MEDA Philosophy
Maintenance errors are caused by a series of contributing factors
MEDA Philosophy
Violations, while intentional, are also caused by contributing factors
MEDA Philosophy
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.
MEDA Philosophy
Developed by Boeing in 1992
MEDA
Used to help address errors and eventually even violations
MEDA Investigation Process
MEDA Investigation Process:
1.
Event Occurs
MEDA Investigation Process:
2.
Investigation find that event was caused by technician/inspector performance
MEDA Investigation Process:
3.
Find the maintenance technician/inspector who did the work
MEDA Investigation Process:
4.
Interview the person
MEDA Investigation Process:
4. Objectives in interviewing the person
- Find error/violations
- Find contributing factors
- Get ideas for process improvement
MEDA Investigation Process:
5. __ to get all relevant contributing factors information
Carry out follow-up interview
MEDA Investigation Process:
6. ___ to a maintenance event database
Add the result from investigation information
MEDA Investigation Process:
7.
Make process improvements
MEDA Investigation Process:
7. Make process improvements based on:
- This event
2. Data from multiple events
MEDA Investigation Process:
8. ___ affected by the process improvements
Provide feedback to all employees
Accurate and timely reporting of relevant information related to hazards, incidents, or accidents is a fundamental activity of safety management.
Safety Reporting
The data used to support safety analyses are reported by multiple sources.
Safety Reporting
One of the best sources of data is direct reporting from?
Front-line personnel
Prerequisite for effective safety reporting
Personnel have been:
- Trained
- Encouraged to report errors and experiences
Things, situations, activities, or conditions can bring harm and can cause lives.
Hazard
Identifying ___ is one way to prevent ___
- Hazard
2. Accidents
Safety Management is caused by _____
Safety Hazard Reporting
_____ is caused by Safety Hazard Reporting
Safety Management
To prevent hazards
Reporting hazards
Through safety hazard reporting the management will be able to:
- Identify the hazard
2. Improve safety
Five Basic Characteristics of Effective Safety Reporting
- Willingness
- Information
- Flexibility
- Learning
- Accountability
Characteristic:
People are willing to report their errors and experiences
Willingness
Characteristic:
Management should be a culture of willingness
Willingness
Characteristic:
Related to communication and trust between the employees and the management.
Willingness
Characteristic:
People are knowledgeable about the human, technical, and organizational factors that determine the safety of the system.
Information
Characteristic:
Trained to report the proper risks.
Information
Characteristic:
Knowledgeable enough to know if a certain event is already a hazard.
Information
Characteristic:
Because you have a realistic view of the hazard you know the damage.
Information
Characteristic:
People can adapt reporting when facing unusual circumstances, shifting from the established mode to a direct mode.
Flexibility
Characteristic:
Allowing information to quickly reach the appropriate decision-making level.
Flexibility
Characteristic:
People have the competence to draw conclusions from safety information systems.
Learning
Characteristic:
The will to implement major reforms.
Learning
Characteristic:
People are encouraged and rewarded for providing essential safety-related information.
Accountability
Characteristic:
There is a clear line that differentiates between acceptable and unacceptable behavior.
Accountability
Types of Reporting
- Online reporting
- Hotline reporting
- Verbal reporting
- Hard copy reporting
Organizational literature proposes three characterizations of organizations, depending on how they respond to information on hazards and safety information management.
Westrum Organizational Culture
Westrum Organizational Culture is created by?
Ron Westrum
What did Ron Westrum invent?
Westrum Organizational Culture
Three characterizations of organizations:
- Pathological
- Bureaucratic
- Generative
Westrum:
Hides the information.
Pathological
Westrum:
Power-oriented
Pathological
Westrum:
Restrains the information
Bureaucratic
Westrum:
Rule-oriented
Bureaucratic
Westrum:
Many factors must be considered that’s why the process is slow phased.
Bureaucratic
Westrum:
Values the information.
Generative
Westrum:
Goal-oriented
Generative
___ is characterized by the beliefs, values, biases, and their resultant behavior that are shared among members of safety, group, or organization.
Culture
Set of values, behaviors, and attitudes
Culture
Encouraging or giving confidence to the employees to report hazards.
Safety Culture
One of those nebulous things, like safety management.
Safety Culture
Behavior and performance of employees when no one is watching.
Safety Culture
You cannot see it or touch it. You can only see evidence or absence of its existence.
Safety Culture
It is not something you get or buy; it develops over time and must be maintained.
Safety Culture
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.
Positive Safety Culture
Like trust, ____ takes time and effort to establish and can be easily lost.
Positive Safety Culture
Created by Patrick Hudson
Safety Culture Maturity Model
Developed back in 2000s (2003)
Safety Culture Maturity Model
The model specifies at which level the hazard is.
Safety Culture Maturity Model
The model which is increasingly informed
Safety Culture Maturity Model
The model which is increasing in trust and accountability
Safety Culture Maturity Model
Five-step progression of Safety Culture Maturity Model
- Pathological
- Reactive
- Calculative
- Proactive
- Generative
Maturity Model:
Who cares as long as we are not caught?
Pathological
Maturity Model:
No care safety culture
Pathological
Maturity Model:
“Who cares” approach
Pathological
Maturity Model:
Business is top priority
Pathological
Maturity Model:
Also known as emerging
Pathological
Maturity Model:
Safety is important, we do a lot every time we have an accident
Reactive
Maturity Model:
Safety is regarded as a burden
Reactive
Maturity Model:
Fix to blame approach
Reactive
Maturity Model:
They see accidents are caused by employees
Reactive
Maturity Model:
Also known as managing
Reactive
Maturity Model:
There are systems in place to manage all hazards
Calculative
Maturity Model:
Many audits are collective which will be used to improve the system.
Calculative
Maturity Model:
The mindset of the management is the system they have is already enough.
Calculative
Maturity Model:
Complacency
Calculative
Maturity Model:
Everything is cased by what happened in the past
Calculative
Maturity Model:
Safety is not the core value
Calculative
Maturity Model:
Also known as involving
Calculative
Maturity Model:
Safety leadership and values drive continuous improvement.
Proactive
Maturity Model:
They aim to anticipate the problems before it happens.
Proactive
Maturity Model:
They consider factors that might go wrong in the future
Proactive
Maturity Model:
They act before future mistakes may happen.
Proactive
Maturity Model:
Safety is top priority
Proactive
Maturity Model:
They use bad news to further improve the system.
Proactive
Maturity Model:
Safety is the core value
Proactive
Maturity Model:
Also known as cooperating
Proactive
Maturity Model:
Generate High-Reliability Organization (HRO), Health, Safety, and Environment (HSE)
Generative
Maturity Model:
That is how we do business around here.
Generative
Maturity Model:
They use failure to improve, not to blame
Generative
Maturity Model:
Never think that their system is never enough.
Generative
Maturity Model:
Despite all their efforts, they believe that accidents may and will occur.
Generative
Maturity Model:
Safety environment is a top priority. (Core Value)
Generative
Maturity Model:
Safety is not driven by numbers, but by a core value that safety is an integral part of the operation.
Generative
Maturity Model:
Safety improvement is investment, not a cost
Generative
Maturity Model:
They have outstanding communication with their workforce.
Generative
Maturity Model:
Also known as continually improving
Generative
If “A” exists, then “B” will occur.
Cause-In-Fact
If “A” exists, the the the probability of “b” occurring increases.
Probabilistic
There are few “cause-in-fact” occurrences in the ____ world
Maintenance technician/inspector’s
MEDA Event Model:
Figure 1:
Contributing factors -> error:
Almost all causes are
Probabilistic
MEDA Event Model:
Figure 1:
Error -> event:
it is possible to have some
Cause-In-Fact
MEDA Event Model:
Figure 3:
There is a probabilistic relationship between:
- Contributing factors and an error
2. An error and an event
MEDA Event Model:
Figure 4: There are ___ contributing factors to each error
3 to 5
MEDA Event Model:
Figure 5: There are ____ to the contributing factors
Contributing factors
MEDA Event Model:
Figure 5:
Ask why how many times?
5 times
MEDA Event Model:
Two ways that a violation can contribute to an event
Figure 6 and 7
MEDA Event Model:
Figure 6:
The maintenance technician does not use a torque wrench when called out in the maintenance manual
Violation
MEDA Event Model:
Figure 6:
He under torques the bolt
System Failure
MEDA Event Model:
Figure 6:
Air turn back
Event
MEDA Event Model: Figure 6: Reasons for not using torque wrench: - There was no torque wrench - Work norm to not use a torque
Contributing factors
MEDA Event Model:
Figure 7:
Failure to carry out an operational check
Violation
MEDA Event Model:
Figure 7:
Failure to carry out an operational check at the ___ of the procedure would catch an error.
End
MEDA Event Model:
If the technician failed and then the inspector failed the system an event will occur
Figure 8: Combined Violation Model
MEDA Event Model:
Summarization of causational events
Figure 9: Final MEDA Event Model
MEDA Event Model:
Interprets the theoretical bases of MEDA
Figure 9: Final MEDA Event Model
MEDA Event Model:
Final event causation model that includes errors and violations
Figure 9: Final MEDA Event Model
MEDA was developed by?
Boeing
When was MEDA developed?
1992
The potential outcome of the hazard.
Consequence
A potential source of damage.
Hazard
Projected likelihood and severity of the consequences or outcome from an existing hazard or situation.
Safety Risk
While the outcome may be an accident, intermediate unsafe event/consequences may be identified as – the most credible outcome.
Safety Risk
Addresses, analyses, and mitigates all risks.
Risk Management
Reduces the hazard at an acceptable level/
Risk Management
The likelihood of how often an unsafe event might occur.
Safety Risk Probability
One way to determine the probability of hazards.
Records
How many people are likely to get involved with this hazard.
Safety Risk Probability
Probability:
Likely to occur many times
Frequent
Probability:
Has occurred frequently
Frequent
Probability:
Value of 5
Frequent
Probability:
Likely to occur sometimes
Occasional
Probability:
Has occurred infrequently
Occasional
Probability:
Value of 4
Occasional
Probability:
Unlikely to occur, but possible
Remote
Probability:
Has occurred rarely
Remote
Probability:
Value of 3
Remote
Probability:
Very unlikely to occur
Improbable
Probability:
Not known to have occurred
Improbable
Probability:
Value of 2
Improbable
Probability:
Almost inconceivable that the event will occur
Extremely Improbable
Probability:
Value of 1
Extremely Improbable
After knowing the probability, you must then assess or identify the ___
Safety Risk Severity
The extent of harm that might reasonably occur as a consequence or outcome of the identified hazard.
Safety Risk Severity
The extent of the damage
Safety Risk Severity
The extend of the hazard
Safety Risk Severity
The environmental impact which can be identified using questions.
Safety Risk Severity
Severity:
Equipment destroyed
Catastrophic
Severity:
Multiple deaths
Catastrophic
Severity:
Value of A
Catastrophic
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.
Hazardous
Severity:
Serious injury
Hazardous
Severity:
Major equipment damage
Hazardous
Severity:
Value of B
Hazardous
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.
Major
Severity:
Serious incident
Major
Severity:
Injury to persons
Major
Severity:
Value of C
Major
Severity:
Nuisance
Minor
Severity:
Operating limitations
Minor
Severity:
Use of emergency procedures
Minor
Severity:
Minor incident
Minor
Severity:
Value of D
Minor
Severity:
Few consequences
Negligible
Severity:
Value of E
Negligible
Also known as Safety Risk Index or Risk Index
Safety Risk Assessment Matrix
Combination of the result of the probability and the assessment of the severity of the hazard.
Safety Risk Assessment Matrix
Safety Risk Tolerability Matrix:
3 Regions:
- Intolerable region
- Tolerable region
- Acceptable region
Tolerability Matrix:
High-risk
Intolerable
Tolerability Matrix:
Unacceptable under any circumstances
Intolerable
Tolerability Matrix:
The probability and/or severity of the consequences and the damaging potential of the hazard is a threat to safety.
Intolerable
Tolerability Matrix:
Immediate mitigation is required
Intolerable
Tolerability Matrix:
The risk is unacceptable at any level
Intolerable
Tolerability Matrix:
The risk is acceptable but further analysis is required.
Tolerable
Tolerability Matrix:
Medium risk
Tolerable
Tolerability Matrix:
Acceptable provided that acceptable mitigation strategies are implemented.
Tolerable
Tolerability Matrix:
Low risk
Acceptable
Tolerability Matrix:
The risk is acceptable as it currently stands.
Acceptable
Tolerability Matrix:
Acceptable as they currently stand.
Acceptable
Overall Management
Safety Risk Management
The assessment and mitigation of safety risks.
Safety Risk Management
It assesses the risks associated with the identified hazards.
Safety Risk Management
Develops and implements effective and appropriate mitigations.
Safety Risk Management
A key component of the safety management process at both the State and product/service provider level.
Safety Risk Management
HIRA meaning
Hazard Identification Risk Assessment
Probability:
5 Safety Risk Probability
- Frequent
- Occasional
- Remote
- Improbable
- Extremely Improbable
Severity:
5 Safety Risk Severity
- Catastrophic
- Hazardous
- Major
- Minor
- Negligible
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