9.8 Flashcards
(41 cards)
What is the SHELL model?
Software
Hardware
Environment
Live ware (other)
Live ware (you)
What is Software? (SHELL)
Includes maintenance procedures, AMM’s and check lists
What is Hardware? (SHELL)
This is tools, test equipment, aswell as the layout of the aircraft and flight deck
What is Environment? (SHELL)
This is the physical environment of the hangar and environment of the structures provided/ not provided
What is Live ware (others)? (SHELL)
Includes other engineers, supervisors, planners and flight crews and there interface/ intervention they have in the error model
What is Live ware (you)? (SHELL)
This is you and your interface with the error model and how human interaction has the potential to stop errors
What is the ‘PEAR’ model?
People
Environment
Actions
Resources
What is People? (PEAR)
Considers the human capability, suitability and limitations. The model uses this to identify potential risks within the human interface.
What is Environment? (PEAR)
Considers the suitability of the physical environment (lighting, temp, weather) and organisational environment at reducing error and danger.
Includes org and safety culture, norms, leadership, supervision quality and ratio.
What is Action? (PEAR)
Concerns the actions people perform. Using JTA it collects info on what knowledge, skill, instructions, and resources are needed to perform a job. The model uses a plan to help eliminate error
What is JTA?
Job Task Analysis
What is Resources? (PEAR)
A mix of all the other PEAR parts. It focuses on complete resources. Tangible: tools, equipment, and AMM’s
Intangible: number of qualified staff, time allocation, communication.
What is the ‘Swiss Cheese Model’?
An error model that implements multiple safe guard defences. However, not all defensive techniques are perfect therefore have holes. If holes line up, danger will occur. Doesn’t stop latent errors.
What is a ‘latent error’?
An error that has been made at some point and is lying dormant. This could be an error occurring in the design stage of an aircraft.
What is the ‘Error Chain’?
An error model that consists of a chain of errors or negative events that at any point could be broken by querying or recognising error. This can include latent errors and be stopped by the simplest thing (pilot pre flight walkaround)
What is a ‘Slip’?
Actions not carried out as intended or planned. (Mixing up a sequence of steps) Occurs during task execution
What is a ‘Lapse’?
Missing out an action due to forgetting. (Forgetting to lock the tool box after removing tools)
What is a ‘Mistake’?
An error made that was believed to be correct. (Using the wrong sized bit believing it was correct) Caused by faulty planning or intention
What is a ‘Violation’?
A deliberate/ illegal action that can cause damage or harm. (Deviating from procedure because it is quicker) May occur due to short time frame
What is ‘Variable error’?
Considered Variable in nature therefore, cannot be foreseen and are much harder to predict. (Marshalling an aircraft into a light poll)
What is a ‘Constant error’?
Follows a certain, consistent but erroneous pattern. Can be predicted and therefore controlled. When enough is known it is easier to anticipate. (Incorrect APU shutdown procedure)
What is a ‘Skill based error’?
Actions which are learned by routine or motor programmes.
What is an ‘Action slip’ error?
It is Skill based and is essentially a slip, an action which has an unintended outcome and occurs due to a lack of paying attention
What is an ‘Environmental Capture’ error?
A skill based error when an engineer performs the same task in the same environmental circumstance making it into a habit even if it was not needed.
