9.8 Human Error Flashcards
(17 cards)
what are the 4 different models and theories used to illustrate human error
‘SHELL model’
‘PEAR model’
‘error chain’
‘swiss cheese model’
what does each letter on the ‘SHELL model’ represent
S - software
H - hardware
E - environment
L - live-ware (others)
L - live-ware (you)
what does each letter of the ‘PEAR model’ represent
P - people
E - environment
A - actions
R - resources
how can you identify a slips, lapses and mistake
by asking questions like:
were the actions directed by some prior intention
did the action proceed as planned
did they achieve their desired end
what is a slip
actions which were not carried out as intended or planned
what is a lapses
missed actions and omissions
what are mistakes
a specific type of error caused by a faulty plan or intention
what are some other types of errors
design versus operator induced errors
variable versus constant error
reversible versus irreversible error
skill based behaviours and associated errors
what is a type 1 error
when a good item is incorrectly identified as faulty
what is a type 2 error
when a fault is over looked
in violations in aircraft maintenance, what does ROSE stand for
Routine
Optimising
Situational
Exceptional
what is MORS
mandatory occurrence reporting system
who must all incident be reported to
CAA
what is CHIRP
Confidential Human Factors Incident Reporting Programme
what are the aims of error management
to prevent errors from occurring
to eliminate or mitigate the impacts of errors
who is ultimately responsible for taking utmost care of their work and keeping an eye out for error
the engineer
