Human Error Flashcards
When assessing an accident should human factors be the starting point or the ending point?
It should be the starting point. Ending with “the pilot should have” does not answer questions that we need to know.
What is the primary bias in Aviation?
Hindsight
Are initial human factor assessments a symptom or a cause?
Symptom- the real question is why and which location of error is being talked about (i.e. outcome, process, regulations, procedures, training, etc)
True or false- there is a tight coupling between process and outcome…
False- there is a LOOSE coupling. If everything is done wrong and a completed flight is accompished- does anyone know or care?
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?
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.
True or False- incidents involve only one failure/factor ?
False- they involve SEVERAL different factors (chain of errors)
True or False- some factors in an incident are always present and are imbedded in the system.
True- why else have back-ups
What creates pilot expertise and errors?
All factors imbedded in the system. Errors and knowledge come from same source.
True or False- errors are for the most part predictable
True- lawful factors help decide what types of errors to expect
True or False- Assessments and actions should not be based on context in which they happened?
False- it should.
What three things must be used to enhance safety?
1) enhanced error detection
2) enhanced tolerance
3) enhanced recovery
True or False- systems will fail. It’s how you handle that failure that you become safe.
True
The sharp end is where ____________ occurs.
Failure
The blunt end is the _____________ of the error.
Beginning
True or False- if we fool proof a system, the system will create a better fool.
True- the design or artifacts affects potential for errors and leads to different paths to disaster.
True or False- latent failures in the system will lead the operator to use unsafe acts to compensate for a flawed system.
True
What does HFACS stand for?
Human Factors Analysis and Classification System.
What three things do Preconditions for Unsafe Acts break down into?
1) Environmental Factors
2) Condition of Operator
3) Personnel Factors
Condition of Operator breaks down into 3 categories. What are those categories and what do they mean?
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.
Personnel factors splits off into 2 categories. Name and explain them both.
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
Environmental Factors splits into 2 categories- name and explain them both.
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
What 2 categories come about unsafe acts and what is the main difference between the two?
Errors and Violations. Errors are not intended whereas Violations are willful.
Name and describe the three types of errors.
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
Name and describe the two types of violations.
1) routine- done on a routine basis. all the time. i.e. speeding
2) exceptional- rarely done. i.e. vehicular manslaughter
Describe ergonomics and the optimum eye datum point.
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.
