Human Error Part 2 Flashcards
What are the three performance levels?
- Skill-based
- Knowledge-based
- Rule-based
For which tasks is the skill based performance level relevant?
Routine, highly practised tasks. Largely automated fashion. Occasional conscious checks for performance.
How much conscious attention is required for skill based tasks?
Not much need for conscious attention. Vulnerable if the attention is diverted even momentarily.
With which two types of error is the skill-based performance level associated?
- Lapse
- Slips
What are slips?
Failures in carrying out the actions of tasks.
Give examples of slips in tasks.
- Performing an action too late in the procedure
- Carrying out an action with too much or too little strength
- Carrying out an action in the wrong direction
- Doing the right think on the wrong object
What is a lapse?
- Lose our place
- Forget to carry out an action
For which tasks is the rule-based performance level relevant?
There is a need to programme our largely pre-programmed behaviour. The problem is typically one we have encountered before.
How is rule-based performance developed?
Through training and/or experience.
How do we largely operate at the rule-based performance level?
Operate largely on pattern matching
With which error is rule-based performance level associated?
Mistakes
What is the problem with mistakes?
You do the wrong thing believing it is the right thing
What aspects of our mental process do mistakes involve?
How we plan, assess information and make intentions
When do rule-based mistakes occur?
When our behaviour is based on remembering rules or familiar procedures.
What is the tendency with mistakes?
There is a strong tendency to use familiar rules or solutions.
When is the knowledge-based performance level used?
Repeatedly failed to find a solution using known methods
What is the problem with thinking things through on the spot in knowledge-based performance level?
It is highly error prone because knowledge is patchy or inaccurate.
What error is associated with knowledge based performance level?
Mistakes
What is the action and intention of a mistake?
The intention is wrong and the actions align with the intention. However, the mistake is performed because you believe you are doing something right.
When are knowledge-based mistakes made?
In unfamiliar circumstances when we revert consciously back to making plans and procedures.
What is the result of a knowledge based mistake?
Planning or problem solving needs to use first principles and analogies. There can be misdiagnosis and miscalculations can result.
What is the relationship between time and knowledge-based performance level?
If there was enough time then we would be able to produce good solutions. However time is not always available for example in an emergency.
What is associated with:
- mainly conscious, automatic control mode
- Novel, difficult or dangerous problem
Knowledge-Based Performance Level
What is associated with:
- conscious and automatic control mode
- Familiar or trained for problems
Rule-Based Performance Level
What is associated with:
- mainly automatic control mode
- routine, expected
Skill-Based Performance Level
What is a violation?
Deliberate deviation from rules, procedures, instructions and regulations
What is the result of violation of health and safety procedures?
Many accidents and incidents
Give an example of a health and safety violation
Not wearing PPE
Why do people violate?
Because they want to be able to carry out a task faster. Rarely is it associated with malicious intent.
What are the three categories for a violation?
- Exceptional
- Routine
- Situational
When does an exceptional violation occur?
When something has gone wrong
When does a routine violation occur?
Normal way of working within the group. Desire to save time and energy and believe that the rules are too restrictive
When does a situational violation occur?
Breaking due to pressure - time pressure, not enough staff etc.
