Weeks 5 & 6 - Safe or Not Safe?

Question 1

Performance Levels (3 key points)

Answer 1

• Skill-based
• Rule-based
• Knowledge-based

Question 2

Error Types (3 key points)

Answer 2

• Slip (incorrect action after correct plan)
• Lapse (forgotten action after correct plan)
• Mistake (failure in plan of action, or incorrect plan)

Question 3

Errors and Performance Levels

Answer 3

Skill-based performance:
- Slips
- Lapses

Rule-based performance:
- Mistakes

Knowledge-based performance:
- Mistakes

Question 4

Violation types and definitions (3 key points)

Answer 4

Routine:
- One that becomes part of the person’s automated routines

Situational:
- Cuts corners to get the job done

Exceptional:
- Rare occurrences in unusual situations, either from deliberate action or instinctive reactions.

Question 5

Aspects of error management (5 key points)

Answer 5

• Prevention
• Reduction
• Detection
• Recovery
• Tolerance

Question 6

Aspects of violation management (4 key points)

Answer 6

• Allow discussions of difficulties and solutions
• Analyse existing and potential violations
• Reduction of violations through good leadership and planning
• Ensure awareness of responsibility and key risks

Question 7

Definitions: Normalisation of Deviance

Answer 7

When established standards are subverted incrementally over time without consequence by rewarding shortcuts from the norm.

Question 8

Consequences of normalisation of deviance (4 key points)

Answer 8

• Predictable surprises
• Incursion of risk factors
• Technical failures
• Catastrophic failures

Question 9

How does the swiss cheese model work?

Answer 9

• Cheese slices represent defence from errors or violations; factors to accidents.
• Holes represent weaknesses in barriers against factors.
• When all holes are passed through, undesirable outcomes occur.

Question 10

Aspects in the Human Factors Analysis and Classification System (HFACS) framework (4 key points)

Answer 10

• Operational influences
• Supervisory factors
• Preconditions for unsafe acts
• Unsafe acts

Question 11

Aspects of S.H.E.L. Model (4 aspects)

Answer 11

S - Software (procedures/training)
H - Hardware
E - Environment
L - Liveware (humans)

Question 12

Factors of SHEL’s Liveware aspect (4 factors)

Answer 12

• Physical (physical body)
• Physiological (mental health)
• Psychological (mental well-being)
• Psychosocial (personal relations/issues)

Question 13

Murphy’s Law

Answer 13

Anything that can go wrong will go wrong.

Question 14

Aspects of the 5-M model (5 aspects)

Answer 14

• Man
• Machine
• Medium (environment)
• Mission (purpose)
• Management