Progress Test Flashcards
What are the 4 conditions for an accident to occur according to the James reason Swiss cheese model?
What type of failures must occur at each stage for an accident to occur?
ORGANISATIONAL INFLUENCES: LATENT;
UNSAFE SUPERVISION: LATENT;
PRECONDITIONS FOR UNSAFE ACTS: LATENT;
UNSAFE ACTS: ACTIVE
What is an active failure?
What are examples of active failures?
UNSAFE ACTS that have IMMEDIATE negative CONSEQUENCE, usually CAUSED by INDIVIDUAL;
SLIPS, LAPSES, FUMBLES, MISTAKE and PROCEDURAL VIOLATIONS
What is a latent failure?
What effects can they translate to in the workplace? Give examples?
What can they create? Give examples?
Consequences lay dormant to be ACTIVATED at a LATER stage, usually CAUSED by the SYSTEM;
Can translate into CONDITIONS within LOCAL workplace such as TIME PRESSURE, UNDERSTAFFING, FATIGUE or INEXPERIENCE;
Can CREATE LONG LASTING HOLES or WEAKNESS in DEFENCES caused by UNTRUSTWORTHY ALARMS/INDICATORS or DESIGN/CONSTRUCTION DEFICIENCIES
What are the 5 M’s in the 5M model?
HUMAN (Pilot); Machine (Aircraft); MISSION (Flight); MANAGEMENT; MEDIUM (Physical environment)
How do the 5M’s interrelate?
The HUMAN operates a MACHINE to complete a MISSION;
The MANAGEMENT tasks this MISSION and is RESPONSIBLE for ensuring the CREW and AIRCRAFT conform to REGULATORY REQUIREMENTS (SOCIETAL) and the AIRCRAFT is capable of ENDURING the demands of the aeronautical MEDIUM (PHYSICAL)
What is error in the aviation environment defined as?
An UNINTENTIONAL ACTION or INACTION that leads to DEVIATION from crew or organisational INTENTIONS or EXPECTATIONS
What is a violation?
INTENTIONAL ACTIONS or INACTIONS which VIOLATE KNOWN rules, procedures or norms. A CONSCIOUS DECISION, not following SOPs for instance
What are the 3 further developed types of error?
SLIPS;
LAPSES;
MISTAKES
How can mistakes, lapses and slips be defined?
What stages can they be classified into?
MISTAKES: failures of EXPERTISE or LACK of experience (PLANNING stage)
LAPSES: internal, usually involving FAILURE of MEMORY (STORAGE stage)
SLIPS: EXECUTION INCORRECT, expectation and habit play a part (EXECUTION stage)
What model describes the 3 levels of cognitive control?
What are the 3 levels?
Rasmussens SRK model;
SKILL, RULE, and kNOWLEDGE based errors
How can a knowledge based error be described?
How may an individual respond when in this level of performance?
Give an example of this?
Situation is NOVEL, decision makers will NOT have any RULES STORED from experiences;
Analytical PROCESSING using CONCEPTUAL information;
PROBLEM SOLVING rather than DECISION MAKING, using problem definition, solution generation, determining which course of action might be successful;
STUDENT PILOT makes error due to LACK of KNOWLEDGE of a situation
How can a rule based error be described?
Give an example of this?
A FAMILIAR situation but not extensive experience;
CUES are RECOGNISED meaning certain things/signs;
Signs TRIGGER RULES accumulated FROM PAST experience;
Rules are if-then ASSOCIATION between CUE sets and appropriate ACTIONS;
CO PILOT makes an error resulting from the MISCLASSIFICATION of a situation with an APPLICATION of the WRONG RULE
How can a skill based error be described?
Give an example of this?
A FAMILIAR TASK with extreme experience;
React at AUTONOMOUS level;
DO NOT have to INTERPRET cues or THINK of actions;
Performance is governed by PURE STIMULUS RESPONSE;
EXPERIENCED CAPTAIN makes error when his automated sequence of events is interrupted
At what cognitive control stage do slips and lapses occur?
Why might they occur?
Typically at the SKILL BASED level;
Simply FORGETTING to carry out a normal or abnormal TASK such as a fuel drain
At what cognitive control stage do mistakes occur?
Why might they occur?
CONSCIOUS DECISION making occurring at the RULE and KNOWLEDGE based stages;
NOT IDENTIFYING the SITUATION correctly or NOT KNOWING the correct SOLUTION/RULE to apply
How can violations be categorised?
What cognitive level do they correlate with?
ROUTINE: NORMALISED and common (SKILL based);
SITUATIONAL: SHORTCUT at expense of safety (RULE based);
EXCEPTIONAL: UNUSUAL circumstances (KNOWLEDGE based)
What are the 5 main countermeasures implemented to better error management?
What does each aim to achieve?
Error PREVENTION: preventing the error altogether (usually requires design based solutions)
Error REDUCTION: minimising the likelihood and magnitude of the error (ergonomics)
Error DETECTION: making errors apparent as fast and as clearly as possible so that it may be detected by the person that committed the error, cued by the environment or detected by another person;
Error RECOVERY: making it easy to rapidly recover the system to a safe state after the error
Error TOLERANCE: making the system as tolerant as possible towards error
What is an example of error prevention?
A CLASSIC MANUAL engine start routine introduces POTENTIAL for ENGINE DAMGE through human ERROR through INCORRECT TIMING and CUTTING FUEL flow. The AUTO engine start on FADEC equipped aircraft PREVENTS these ERRORS by precise MONITORING of key engine PARAMETERS, CORRECT TIMING of each step and AUTO SHUT-DOWN if anything ABNORMAL occurs during start
What is an example of error reduction?
Applying good ERGONOMICS to the COCKPIT DESIGN such as SHAPING the FLAP, SPOILER, and LANDING GEAR levers to SYMBOLISE their FUNCTIONS to give both VISUAL and TACTILE cues and REDUCE SLIPS involving using the wrong lever
What are so examples of error detection?
Performance calculation software can WARN the flight CREW when some INPUT values are OUTSIDE reasonable RANGE;
CROSSCHECKING which facilitated DETECTION by ANOTHER PERSON;
FORCING FUNCTIONS which force crew to DETECT and CORRECT an ERROR before continuing with the task
What is an example of error tolerance?
CONSERVATIVE operational MARGINS in performance models ensure that reasonably SMALL ERRORS in aircraft LOADING and WEIGHT and BALANCE calculations DO NOT ENDANGER flight in CRITICAL PHASES
What is an example of error recovery?
The UNDO FUNCTION in COMPUTER software
What are the dirty dozen
Complacency; Distraction; Fatigue; Pressure; Stress; Norms; Lack of: Communication; Knowledge; Teamwork; Resources; Assertiveness; Awareness
What are the 2 approaches to investigating errors?
Briefly explain each one?
PERSON approach:
BLAME an INDIVIDUAL for the error due to factors such as mental processes including forgetfulness, inattention, poor motivation, carelessness, negligence and recklessness.
SYSTEM approach:
ACCEPTING that errors are MADE and CONTAINED WITHIN a system
What are the types of bias and heuristics?
EXPECTATION bias;
CONFIRMATION bias;
AVAILABILITY heuristic
What is expectation bias?
What may this lead a person to do?
What is an example of this?
FILLS in BLANKS in COMMUNICATION to understand incomplete messages;
A person may hear what they WANT or EXPECT to hear;
A pilot may be REGULARLY CLEARED to cross a particular runway during operations at a FAMILIAR AERODROME, they may come to EXPECT the CLEARANCE and one day INSTRUCTED NOT to CROSS the runway due to another aircraft LANDING or TAKING OFF then possibly CONTINUE onto the runway
What is confirmation bias?
What may this lead a person to do?
What is an example of this?
Creates a HYPOTHETICAL DIAGNOSIS which is difficult to counter;
A person may DISREGARD information that CONTRADICTS their mindset;
KEGWORTH disaster: Fan blade broke in the LEFT ENGINE, disrupting AIRCON and filling cabin with SMOKE, pilots believed the FAULT was in RIGHT ENGINE as earlier models of 737 ventilated from the RIGHT. The pilots shut down the RIGHT and WORKING ENGINE and caused fuel supply to go to LEFT BROKEN ENGINE and cause it to catch FIRE
What is availability heuristic?
What is an example of this?
Occurs when WORKLOAD is HIGH and the brain puts more emphasis on the MOST AVAILABLE information RATHER than MOST RELIABLE and RELEVANT;
Eastern Airlines Flight 401, ALL CREW FIXATED on nose gear LIGHT NOT ILLUMINATING, do NOT REALISE they are DESCENDING and don’t hear audio alert, eventually DESCEND into GROUND
What are the key characteristics of low reliability organisations?
Search for a INDIVIDUAL to blame and CATEGORISE all events as HUMAN ERROR;
Human error is a JUDGEMENT made in HINDSIGHT;
Failures occurring WITHIN the SYSTEM are not identified
What are the key characteristics of high reliability organisations?
RECOGNISE human variability in COMPENSATING and ADAPTING to events is key in SAFEGUARDING an organisation;
EXPECT operators to MAKE ERRORS but train their workforce to RECOGNISE them and RECOVER (MITIGATE);
REHEARSE familiar scenarios of failure and IMAGINE novel ones;
Make SYSTEM REFORMS INSTEAD of LOCAL REPAIRS
What is a normal/human error?
INADVERTENT ACTION: inadvertently doing OTHER than what should have been done (SLIP, LAPSE, MISTAKE)
What is at risk behaviour (negligence)?
BEHAVIOURAL CHOICE that INCREASES RISK where RISK is NOT RECOGNISED or is mistakenly BELIEVED to be JUSTIFIED
What is high culpability behaviour (recklessness)?
BEHAVIOURAL CHOICE to CONSCIOUSLY disregard a SUBSTANTIAL and UNJUSTIFIABLE RISK
What are the components of Reason’s safety culture?
INFORMED culture; LEARNING culture; REPORTING culture; JUST culture; FLEXIBLE culture