Human Errors/Decisions Flashcards
Active Errors
Committed by sharp end people (pilots/ATC etc)
Directly linked to accident
Short lived failures
Latent Errors
Hidden for a long time
Difficult to recognise or foresee due to time lag between occurrence
Cumulative
Manifest themselves under certain conditions
Force sense of security
Types of human errors
Violations - deliberate illegal actions
Omissions - missing out a process or step that should have been included
Faults - wrong drill for the task
Slips - do not meet operators intent but intent itself was correct
Tolerant to errors
When the consequences will not seriously jeopardise safety
Errors and groups
Groups tend to make riskier decision than any group member alone.
Risky shift
Change decision to become more extreme and risky when acting as a group.
James Reasons errors are
Slips/Lapses - correct intent failed execution
Mistakes - you do the wrong thing - failure of action plan
Violations - deliberate action
Error Management Strategies
Error Prevention
Error Reduction
Error detection
Error recovery
Error tolerance
Situational awareness + components
Modelling of a situation
Environmental
Spatial orientation
Time horizon
System awareness
Mode awareness
How can you regain SA?
Reduce workload
Reduce pace of event
Rebuild mental picture
Step back
Take more time to decide
Definition of an error
An error is the mismatch between pilots intention and the result of his her action
KEYWORD INTENTION to carry out an action
Slip is a
An error which the intention was correct but failure occurred in carrying out activity
Mistake is a
A error which arises from incorrect intention leading to incorrect action sequence. A failure of action plan with a flawed outcome
Violations
Deliberate action
Routine - violation to save time/reduce work load
Exceptional - intended good outcome/boredom etc
Internally generated errors
Illness
Skill deterioration
Fatigue
Poor motivation
Distraction
Memory failure
Perceptual error
Externally generated errors
Stressors
High work load
Ergonomics
Economics
Social environment
Environmental capture
Tendency for a skill to be executed in an environment which is frequently exercised even if not appropriate action
Lapses
Errors from forgetting to do something
Successful error management methods x5
Error prevention
Error reduction
Error detection
Error recovery
Error tolerance
TEM countermeasures
Planning Countermeasures - managing and anticipated/unexpected threats (SOP briefing)
Execution Countermeasures - essentials for error detection and error response
Review countermeasure - essential for managing changing conditions of a flight
Behaviour is shaped by
Internal factors - childhood/career/school
External factors - groups etc
Personality is
Our stable behaviour character
Shaped at childhood/past experience
Do not change
Ideal Pilot would be
Stable extrovert
Humanist Model describes
Self Concept - How you see yourself
Self Ideal - how you think you should be
SImilar between the two is more balance and ideal
Different - aggressive/awkward/confused
Maslows Hierarchy Of Needs
Used to explain motivation
Bottom to top:
Physiological needs - food/water
Safety needs - safe environment
Cognitive needs - knowledge/understanding
Aesthetic needs - beauty in ones self
Self actualisations - realising potential/self fulfilment
Hazardous Attitudes
Anti authorisation
Impulsiveness
Sense of invulnerability
Excessive self esteem
Resignation
Resignation
Complacency
Desirable Attitudes
Conscientiousness
Self control
Stable slight extrovert
Agreeable
Synergy in a group
Group performance exceeds sum of all individuals best performance
Each group member motivated to support each other
Group THinking
Desire to reach agreement to override rational decision making
Autocratic Authority Cockpit
Decision without consultation
Disregards opinions of other crew
Little/no team work
- overload//high tension/withdrawal
Laissez Faire Cockpit
Passive decisions/choices by other crew
Hard to determine who’s in control
No form of control or leadership
BAD
Synergistic Ideal Cockpit
Leads by example,motivates, supports team work
DECISION
Define the aim
Collect information
Assess the risk
Develop options
Evaluate options
Decide
Implement
Monitor
Review
A pilot sitting below the eye datum point will normally be unable to see the
Undershoot
Error Chain (unintentional omission)
Multiple errors committed rather than a single one
Invulnerability
It wont happen to me
Impulsivity
Does it quickly
Anti Authority
Don’t tell me what to do
Macho
I can do it attitude
Resignation
What’s the use…
Complacency
Feeling of quiet pleasure or security often unaware of potential danger
Over confidence in oneself
X5 Error Management way of remembering
People
Really
Don’t
Read
Things
Prevention
Reduction
Detection
Recovery
Tolerance
Cooperation
Working together towards the same aim via communication or sharing
Coaction
Working together but does not imply communication or sharing
Cohesion
Also known as solidarity
Degree to which a group hangs together as a tightly knit self contained entity.
Factors that contribute to group cohesion
Stability - relationships
Side - small groups better than smaller ones
Similarity
Success
External threats
Synergy
Groups cooperative and cohesion outweighs the sum of all the groups performance. Outperform even the best member of the group
Interdependence
Each crew member depends on the others to carry out actions which might otherwise be difficult or impossible for one person to perform
Susceptible to group think
Cohesive group
Insulated from external info
Ignore alternative options
Under pressure
Dominated by a directing leader
