Lecture 4 - Human Error Flashcards
Unintentional deviation of failure
Error
Intentional failures
Violation
Failure of a planned action to be completed as intended
Error
– Occur at the level of the frontline operator
– Effects are felt almost immediately.
Active failures
– Tend to be removed from the direct operator control
Latent conditions
2 Approach WHY DO ERRORS HAPPEN ?
Person approach
System approach
Blame the individual for forgetfulness, inattention, weakness
Person approach
Multiple faults that occur together in an unanticipated interaction create chain of events in which faults grow and evolve.
System approach
It is a portion of a task is skipped
Omission
Task is performed incorrectly
Commission
Task that should not have been performed, as it diverts attention from the system
Extraneous act
Task is performed out of sequence
Sequential act
Task performed too early, too late, or outside of time allowed
Time error
What are the 3 stages of cognitive processing for tasks?
1) Planning
2) Storage
3) Execution
Under 3 stages of Cognitive Processing for Tasks where a goal is identified and a sequence of actions is selected to reach the goal
Planning
Under 3 stages of Cognitive Processing for Tasks where the selected plan is stored in memory until it is appropriate to carry it out
Storage
Under 3 stages of Cognitive Processing for Tasks where the plan is implemented by the process of carrying out the actions specified by the plan
Execution
What are the 3 Form of Error?
- Slips: execution stage
- Lapses:: storage stage
- Mistakes: planning stage
incorrect execution of a planned action
example: miss keyed command
Slips
» incorrect omission of a stored, planned action
» examples: skipping a step on a checklist, forgetting to
restore normal valve settings after maintenance
lapses
» the plan is not suitable for achieving the desired goal
mistakes
TRUE or FALSE.
Slips and lapses occur when the task is very unfamiliar and requires little thought.
FALSE
TRUE or FALSE.
Slips and lapses occur when people confuse two similar tasks
TRUE
TRUE or FALSE.
Slips and lapses occur when the main part is missed but the finer details are done
FALSE
TRUE or FALSE.
Slips and lapses occur when tasks are too complicated and long-winded
TRUE
TRUE or FALSE.
Slips and lapses occur when there are distractions and interruptions.
TRUE
TRUE or FALSE.
Mistakes occur when doing few things at the same time.
FALSE
TRUE or FALSE.
Mistakes occur when doing too many complex tasks at once.
TRUE
TRUE or FALSE.
Mistakes occur when time pressures.
TRUE
What does GEMS mean?
Generic Error-Modeling System
an attempt to understand the origins of human error
Generic Error-Modeling System
What are the 3 levels of cognitive task processing identified by GEMS?
- Skill-based
- Rule-based
- Knowledge-based
Levels of cognitive task processing that is familiar, automatic procedural tasks.
Skill-based
Levels of cognitive task processing that the tasks approached by pattern-matching from a set of internal problem-solving rules
Rule-based
Levels of cognitive task processing that the tasks approached by reasoning from first principles
Knowledge-based
Errors that we experience, without intending to, you do the wrong thing.
Slip
Errors that we experience, without intending to, you fail to do what we meant to do.
Lapses
Errors that we experience, without intending to, you mishandle or blunder an action or word.
Fumble
In addressing human error,
general approach:
error-avoidance rather than error-tolerance
or
error-tolerance rather than error-avoidance?
error-tolerance rather than error-avoidance
TRUE or FALSE.
Automation is the cure for human error
FALSE
It is the ability to withstand.
Robustness
What does S.T.A.R means when self-checking?
Stop
Think
Act
Review
Best way to address human error is
tolerance
or
avoidance?
Tolerance
“to err is _____”
Human
