Human Error Classification Flashcards
What are some factors affecting human error?
Function of system design
Task, equipment, procedures, traffic demands
Controller Attributes
Job satisfaction
Fatigue
Lack of skill
Lack of information
Distraction
Multi-tasking
Misunderstanding
What are some types of controller error?
Slips
Lapses
Mistakes
What is a slip?
Intention correct, but not carried out as planned. Likely to be ‘one off’ errors.
What is a lapse?
The controller has failed to do something. Possibly caused by distractions or lack of attention.
What is a mistake?
Action was performed as intended but the plan is faulty. Could be a lack of experience, errors of judgment, or poor controlling techniques.
What is the definition of a violation?
Deliberate action, known to be against the rules.
The ATCO purposefully chose to disregard procedures.
What are the three main types of classification of performance according to the Rasmussen model?
Skill based
Knowledge based
Rule based
What is an active error?
The proximal causes of an accident, for example, the pilot became distracted, leading to an accident.
What is a latent error?
The remaining contributory elements in the organisation: senior managers decisions, line management pressures, unsafe climate and culture coupled with fatigue and confusing warnings. Without these latent errors, accidents can be prevented.
What is a window of opportunity?
Refers to the opportunity for active and latent errors to contribute to an accident. Accidents happen, yet latent errors remain unsolved, waiting for their opportunity to strike. (Swiss-cheese model)
What is the causation chain?
All the related windows of opportunity at all levels align, thus leading to an accident. Therefore the cause of most accidents can be traced through these open windows. (Swiss-cheese model)
What is a skill-based behaviour?
Routine activity conducted automatically and does not require conscious allocation of attentional resources. Determined by stored, preprogrammed patterns of instructions.
Inability to verbalise how behaviour is controlled or explain the background to the behaviour.
What is a rule-based behaviour?
Activities controlled by a set of stored rules or procedures.
Rules can be verbalised and performed based on specific ability.
What is a knowledge-based behaviour?
A behaviour shown in a novel situation for which a plan must be developed to solve a problem. In contrast to set rules, plans must often be changed based on the situation.
Attention must therefore be allocated to the behaviour and the performance is goal-controlled.
Revise the classification of Errors image
