Human Error And Reliability Flashcards
Human reliabilty
The probabilityof humans conductiong specific tasks with satisfactory pefromance
~the organisation
~work conditions
~man machine interface
~procedures and plans
~Number of simultaneos goals: too many goals /tasks at once reduces reliabilty
~available time: lack of available time reduces reliabilty
~time of day: operating within the WOCL reduces reliability
~training and experience: good training and experience increases reliability
Situational awareness
Know where are you know where you going
Situational awerness elements
~personal influnence ~informational influnences ~crew action and behaviour ~environmnetal ingluneces ~organizational influences
Situational awareness influencing factors
Attention Working memeory Stress Mental overload or underload System design and complexity Autonomation Multi crew
Loss of situational awarness
~confusion ~lack of comunication ~use of improper proceducers ~departure from regulations ~failure to meet planned targets ~ambiguity ~fixation
Unsafe acts:
Are either intended or unintended
Human errors
can be SKILL BASED BEHAVIOURS and RULES KNOWLEDGE BASED BAHEAVIOURS:
~SKILL BASED: action slips or envirnomental capture
~RULE KNOWLEDGE BASED:faults mistakes
VIOLATIONS:
Can be routine or exceptional or situational
Active errors
Apparent like pushing an incorrect button,ignoring awaring light.usually involves frontline agents like pilots,air traffic controllers ,operations personnel
Skill based erros
Deciosin errors
Perceptual erros
Latent erros
Refer to concealed or less apparent failures that contributes to the occurrence of errors or allow them to occur.
Poor planning or schedule ,training deficiencies ,lack of motivation ,defective communication
Error generation contributing factors
External factors: ~stressors ~culture /organisation ~workload (excessive) ~ergonomics ~communication ~technical ~envirnomental ~operational
INTERNAL FACTORS: ~perceptual ~memory failure ~skill deterioration ~non standard procedures/cutting edges ~situational awarenss /distraction ~fatugue /physical fitness ~workload poor management ~violation of minima
~Action slip
~Enviromental capture
~action slip :
The performnace of uninteded action
The action may be carried out perfectly but it was the wrong one for the occasion
~enviromental capture: a skill performed in the same environment can become an automatic gesture rather than a conscious one,originating the error
Esternal error gernartion in flight
Ergonomics
Economics
Social enviroment
Error reduction strategies
Autonamition Error cause removal Error tolerance Safety audits Evidence based training Error prevention Error detecition Error detection Error recovery Flight ops quality assurance
Decision makiing
~deciding :an arbitrary process of imediate,unrationalizzed choice between 2 or more options
~decision making:a rational process by which differnt options are analysed
Decision making
Error sources
~confirmation bias ~expectancy bias ~saliency>paying attention for things that stand out ~overconfidence/complacency> ~FATIGUE/OVERLOAD ~denial> ~stress ~lack of experience ~groups ~cognitive biases
Safety awareness
Is the control of recognized hazards and the endeavor of the flight crew to avoid the possibilty of harm to persons or property and to maintian a high level of flight safety