Human Error

Question 0

When assessing an accident should human factors be the starting point or the ending point?

Answer 0

It should be the starting point. Ending with “the pilot should have” does not answer questions that we need to know.

Question 1

What is the primary bias in Aviation?

Answer 1

Hindsight

Question 2

Are initial human factor assessments a symptom or a cause?

Answer 2

Symptom- the real question is why and which location of error is being talked about (i.e. outcome, process, regulations, procedures, training, etc)

Question 3

True or false- there is a tight coupling between process and outcome…

Answer 3

False- there is a LOOSE coupling. If everything is done wrong and a completed flight is accompished- does anyone know or care?

Question 4

There is a route taken by a flight crew to reach a destination. You however decide to take a different route. According to lecture, why might after investigating, have you chosen a different route, and criticized he initial flight crew?

Answer 4

Knowledge of an outcome, biases the judgement about the process. If you know the outcome will be bad taking the original route, you know now that you wouldn’t take that route and now judge the original crew.

Question 5

True or False- incidents involve only one failure/factor ?

Answer 5

False- they involve SEVERAL different factors (chain of errors)

Question 6

True or False- some factors in an incident are always present and are imbedded in the system.

Answer 6

True- why else have back-ups

Question 7

What creates pilot expertise and errors?

Answer 7

All factors imbedded in the system. Errors and knowledge come from same source.

Question 8

True or False- errors are for the most part predictable

Answer 8

True- lawful factors help decide what types of errors to expect

Question 9

True or False- Assessments and actions should not be based on context in which they happened?

Answer 9

False- it should.

Question 10

What three things must be used to enhance safety?

Answer 10

1) enhanced error detection
2) enhanced tolerance
3) enhanced recovery

Question 11

True or False- systems will fail. It’s how you handle that failure that you become safe.

Answer 11

True

Question 12

The sharp end is where ____________ occurs.

Answer 12

Failure

Question 13

The blunt end is the _____________ of the error.

Answer 13

Beginning

Question 14

True or False- if we fool proof a system, the system will create a better fool.

Answer 14

True- the design or artifacts affects potential for errors and leads to different paths to disaster.

Question 15

True or False- latent failures in the system will lead the operator to use unsafe acts to compensate for a flawed system.

Answer 15

True

Question 16

What does HFACS stand for?

Answer 16

Human Factors Analysis and Classification System.

Question 17

What three things do Preconditions for Unsafe Acts break down into?

Answer 17

1) Environmental Factors
2) Condition of Operator
3) Personnel Factors

Question 18

Condition of Operator breaks down into 3 categories. What are those categories and what do they mean?

Answer 18

1) Adverse mental state- not mentally there (i.e. loss of situation awareness)- may be caused by mental stress
2) Adverse physiological state- when your body is not at peak performance (physical fatigue)
3) Physical or mental limitations- lie within. Hazardous Attitudes- anti authority, impulsivity, invulnerability (wont happen to me), macho, resignation.

Question 19

Personnel factors splits off into 2 categories. Name and explain them both.

Answer 19

1) Crew Resource Management (CRM)- breakdown of comm. and coordination between members of the crew
2) Fitness for Duty- personnel readiness- when you are not ready for the tasks

Question 20

Environmental Factors splits into 2 categories- name and explain them both.

Answer 20

1) physical enviornment- hazards of operational enviornment/ambient enviornment. i.e. heat, o2 levels
2) technical enviornment- the effects of new or new uses for technology within occupation

Question 21

What 2 categories come about unsafe acts and what is the main difference between the two?

Answer 21

Errors and Violations. Errors are not intended whereas Violations are willful.

Question 22

Name and describe the three types of errors.

Answer 22

1) Skill Based- basic skills, associated with doing; vulnerable to memory and attention; task technique, poor handeling
2) Decision Errors- have a plan, but plan is inadequate or inappropriate. Procedural. Poor choices. Problem solving.
3) Perceptual- pilot reacts to illusion or disorientation that. Action-not illusion

Question 23

Name and describe the two types of violations.

Answer 23

1) routine- done on a routine basis. all the time. i.e. speeding
2) exceptional- rarely done. i.e. vehicular manslaughter

Question 24

Describe ergonomics and the optimum eye datum point.

Answer 24

Ergonomics- the science of work. How everything is put together. Instruments need to be effective in scanning. Warnings need to be easily seen, heard, and silenced. The eye datum point is the point which will provide proper view of all instrument, outside, and be comfortable.