HFAS Flashcards
Two types of Cost
Human and Economic Cost
terms that are the effects of accident to a worker
disability
loss of income
change in social life
death
Two types of economic cost
direct and indirect
It is a conceptual tool used to analyze the interaction of multiple system components, it provides a basic depiction of the relationship between humans and other workplace components.
Shell model
four components of shell model
software
hardware
environment
liveware
The critical focus of the model is the human participant, or Liveware,
the _____________ component in the system, the front
line of operations.
most critical and most flexible
Humans do not ________ perfectly with the various components
of the world in which they work.
interface
This interface refers to the relationship between the human and the
physical attributes of equipment, machines, and facilities.
The
human-technology interface is generally regarded in aviation operations
concerning human performance, and there is a normal human tendency
to respond to ______ malfunctions.
Liveware - Hardware (L-H)
__________ is the collective term that
refers to laws, rules, regulations, manuals, checklists, publications,
standard operating procedures (SOPs), and computer software.
Software
This interface is the relationship between the human and the supporting
systems found in the workplace.
To achieve safety, effective operation between __________, it is
essential to ensure that the software can be implemented. Also, it
involves issues such as experience recurrence, precision, format and
presentation, vocabulary, clarification, and symbology.
Liveware - Software (L-S)
This interface is the relationship among persons in the work environment.
It is necessary to note that communication and interpersonal skills and group dynamics
play a role in deciding human performance, given that flight crews, air traffic
controllers, aircraft maintenance engineers, and other operational staff work
collaboratively.
The development of crew resource management (CRM) and its
extension to air traffic services (ATS) and maintenance operations have emphasized
handling operational errors across several aviation domains.
Liveware - Liveware
It is a set of training procedures for use in environments where human error can have devastating effects. This is primarily used for improving aviation safety and focuses on interpersonal communication, leadership, and decision making in aircraft cockpits.
Crew Resource Management or Cockpit resource Management (CRM)
Founder of Crew Resource Management
David Beaty
What did David Beaty write?
The Human Factor in Aircraft Accidents
David Beaty was a former _____
Royal Air Force and a BOAC pilot
The interaction between the person and both the internal and external
environments is involved in this interface.
The interaction between the human internal and external
environment is also involved in this interface.
Liveware - Environment
Physical factors such as temperature, ambient light, noise, vibration, and air quality are included in __________
Internal Workplace Environment
Operational factors such as
weather, aviation facilities, and terrain are included in the __________.
External Environment
_____________ may either be caused by the L-E interaction
or derive from external secondary sources, including sickness, exhaustion, financial
uncertainties, and relationship and career issues.
Psychological and physiological forces
According to the SHELL Model, a ________ between
the Liveware and the other four components
contributes to human error. Thus, these
interactions must be assessed and considered in all sectors of the aviation system.
mismatch
It consists of Human, Machine, Medium,
Mission and Management, it represents another valuable visual conceptual model for examining the nature of accidents
The 5-Factor Model
It is a deliberate act or omission to deviate from established procedures, protocols, norms, or practices
violation
It is an unintentional action, inaction or departure from procedures and regulations
error
what is the difference between errors and violations
intent
two types of error
slips and lapses
mistakes
These are failures in the execution of the intended action.
Slips and lapses
These are action that do not go as planned
slips
these are memory failures
lapses
These are failure in the plan of action
Mistakes
What is the cause of errors?
Limitations in our information processing
capabilities and/or skill sets, attention,
resources, knowledge, memory, and motor
skills
What are the result of errors?
An incorrect decision / action
omission or recognition of feedback
How can you manage errors?
Reduction Strategies
Capturing Strategies
Tolerance Strategies
it reduces or prevent errors
reduction strategies
it trap errors before they do any harm
Capturing Strategies
It make our systems error tolerant
Tolerance Strategies
Error Management (Defences)
Error Reduction
Error Capture
Error Tolerance
It aims at avoiding the error
completely. It is possible only in some specific cases
and, almost without exception, requires design-based
solutions.
Error Prevention
IT aims at minimizing both the
likelihood and the magnitude of the error.
Error Reduction
It aims at making errors apparent as
fast and as clearly as possible, thereby enabling recovery.
Error Detection
It aims at making it easy to rapidly
recover the system to its safe state after an error has
been committed.
Error Recovery
It aims at making the system better
able to sustain itself despite the error, i.e., minimizing
the consequences of errors.
Error Tolerance
To further complicate the issue, while violations are intentional acts, they are
not always acts of ________.
malicious intent
two types of violations
situational and routine
These violations violations are committed in response to factors
experienced in a specific context, such as time pressure or high
workload.
Situational violations
These violations become the normal way of doing business within a
workgroup. Such violations are committed in response to situations
in which compliance with established procedures makes task
completion difficult.
Routine Violations
these may continue without consequence,
but over time they may become frequent and potentially severe
consequences.
drift
These violations may be considered as an
extension of routine violations. This type of violation occurs when an
organization attempts to meet increased output demands by ignoring
or stretching its safety defenses.
Organizationally induced
Factors that increase the probability of violations, this set of factors are sometimes called the ‘lethal cocktail’
Expectation
Powerfulness
Opportunities
Poor planning and preparation
4 forms of violation management
Establish channels for people to communicate difficulties and to discuss solutions
Analyze existing violations and assess current violation potential
Reduce violations through good leadership and planning
Management and employees should know their responsibilities
It is characterized by the beliefs, values, biases,
and resultant behavior shared by members of a society,
group, or organization. An understanding of these
cultural components, and the interaction between
them, is essential to safety management.
Culture
Three most influential cultural components are:
organizational, professional, and national cultures
The mix of cultural components may vary significantly among
_______ and can negatively influence effective hazard
reporting, collaborative root-cause analysis, and acceptable risk
mitigation.
organizations
___________ in safety performance is possible when
safety becomes a value within an organization and a priority at the
national or professional level.
Continuous improvement
It refers to the characteristics and
safety perceptions among members interacting within a particular
entity. Organizational value systems include prioritization or
balancing policies covering areas such as productivity versus
quality, safety versus efficiency, financial versus technical,
professional versus academic, and enforcement versus corrective
action.
Organizational Culture
Through personnel selection, education, training, on-the-job
experience, peer pressure, etc., professionals tend to adopt the value
system and develop behavior patterns consistent with their peers or
predecessors.
Professional culture
Professional culture differentiates _________
professional groups characteristics
An ___________ reflects professional
groups’ ability to differentiate between safety
performance issues and contractual or industrial issues. A
healthy professional culture may be characterized as all
professional groups’ ability to address safety performance
issues collaboratively.
effective professional culture
It differentiates the characteristics of nations,
including the individual’s role within society, how authority is distributed,
and national priorities concerning resources, accountabilities, morality,
objectives, and different legal system.
From a safety management
perspective, national culture plays a large part in determining the nature
and scope of regulatory enforcement policies, including the relationship
between regulatory authority personnel and industry personnel and the
extent to which safety-related information is protected.
National Culture
It emerges from personnel beliefs about and
attitudes toward the benefits and potential detriments of reporting
systems and the ultimate effect on their acceptance or utilization of
such systems.
Reporting culture
A ______________ aims to
differentiate between intentional and
unintentional deviations and
determine the best course of action
for both the organization as a whole
and the individuals directly involved.
healthy reporting culture
A culture that fails to distinguish unintentional
errors/mistakes from acts of willful misconduct will inhibit
the ____________.
reporting process
a voluntary
reporting system should be ______________.
confidential and operated following
appropriate non-punitive policies
The system should also provide _________ to personnel on safety
improvements achieved due to the reports received.
feedback
____________ should be collected solely to improve aviation safety,
and information proception is essential in ensuring the continued
availability of information.
Safety information
a safety reporting system must be
confidential, voluntary, and non-punitive
when was the turning point for safety culture
September 11, 1991 - Continental Express Flight 2574
this can be very simply defined as
an organizational commitment to safety at all levels of operation
Safety Culture
Who defined Safety Culture as the
set of enduring values and attitudes regarding safety
issues, shared by every member of every organization level.
EASA ECAST safety management system and safety culture working group
What AC stated that one key aspect essential to safety performance is the organization’s culture.
FAA Advisory Circular, 120-92B (2015)
A safety culture cannot be effective unless it is
embedded within an ______________, where
the ultimate responsibility rests with the
organization’s management (ICAO 2013).
organization’s own culture
___________ where everyone is aware of their roles concerning
safety and all in the organization are truly committed to safety
Positive safety culture
A prerequisite for a positive safety culture is _____________.
good information
The organization
should encourage disclosure of error
without fear of reprisal/punishment,
yet it should also demand
accountability on employees and
management alike.
open reporting
The organization
should identify systemic errors,
implement preventative, corrective
action, and exhibit intolerance of
undesirable behaviors such as
recklessness or willful disregard
for established procedures.
Just Culture
The involvement of line personnel and
all management levels in
functions dealing with aviation
safety, including the accountable
executive, are critical to effective
safety management throughout
an organization.
Personnel Involvement
The effective use of all
safety information assures informed
management decision-making.
Use of Information
The
organization expects direct
management involvement in
identifying hazards and managing risk.
Commitment to Risk Reduction
Processes that provide vigilance of ongoing operations and
the environment to ensure the effectiveness of risk controls and
awareness of emerging hazards.
Vigilance
Using information effectively to adjust and change reduces
risk and a willingness to commit resources to make changes necessary
to reduce risk.
Flexibility
The organization learns from its failures and those of allied
and similar businesses. The organization uses acquired data to feed
analysis processes, yielding information that can be acted upon to
improve safety.
Learning
Three types of culture that Westrum created
Pathological,
Bureaucratic, and
Generative,
The organization cares less about safety than
about not being caught.
Pathological
The organization looks for fixes to accidents and
incidents after they happen.
Reactive
The organization has systems to manage hazards;
however, the system is applied mechanically.
Staff and management
follow the procedures but do not necessarily believe those procedures
are critically important to their jobs or the operation.
Calculative
The organization has systems in place to manage
hazards, and staff and management have begun to acquire beliefs
that safety is genuinely worthwhile
Proactive
Safety behavior is fully integrated into
everything the organization does. The value system associated
with safety and safe working is fully internalized as beliefs, almost
to the point of invisibility.
Generative
True safety culture transcends the ____________.
calculative level
This is a systematic approach to managing safety, including the necessary organizational structures, accountability, responsibilities, policies and procedures.
Safety Management System
Four pillars of SMS
Safety Policies & Objectives (SPO)
Safety Risk Management (SRM)
Safety Assurance (SA)
Safety Promotion (SP)
The state in which risks associated with aviation. activities, related
to, or in direct support of the operation of aircraft, are reduced and controlled to
an acceptable level.
Safety
A condition or object
with the potential of causing injuries to personnel, damage to
equipment or structures, loss of material, or reduction of ability to
perform a prescribed function.
Hazard
The predicted probability and severity of the
consequences or outcomes of a hazard.
Safety Risk
It defines the requirement of the state for an organization to establish a safety program in order to achieve an acceptable level of study
PCAR Part 9
Title of PCAR part 9.7
Safety Management
PCAR part 9 title
Air Operator Certification and administration
ICAO defines SMS guidance in the _________ “Safety Management Manual”
used for the development and implementation of:
State Safety Program
Operators SMS
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