9.8 - Human Errors

Question 1

What models and theories are used to illustrate human error

Answer 1

1. SHELL Model
2. PEAR Model
3. The Error Chain
4. The Swiss Cheese Model

Question 2

What is the SHELL model

Answer 2

1. Software
2. Hardware
3. Environment
4. Live-ware (Others, You)

Question 3

What is software in the SHELL Model

Answer 3

This includes maintenance procedures, maintenance manuals, and check lists

Question 4

What is the PEAR Model

Answer 4

1. People
2. Environment
3. Actions
4. Resources

Question 5

What type of failures can the Swiss Cheese model prevent

Answer 5

Latent errors

Question 6

What is the error chain

Answer 6

Some incidents involve several individuals. Anyone of them could have changed the course of events by reacting or querying a particular action

Question 7

What are the types or errors in maintenance tasks

Answer 7

1. Slips
2. Lapses
3. Mistakes
4. Violation

Question 8

What is a slip

Answer 8

Actions which were not carried out as intended or planned

Question 9

What’s is a Lapse

Answer 9

Missed actions or omissions

Question 10

What is a mistake

Answer 10

A specific type of error caused by a faulty plan or intention

Question 11

What is a violation

Answer 11

They appear to be human errors but are caused deliberately by

Question 12

What is a design induced error

Answer 12

A design flaw

Question 13

What is an operator error

Answer 13

Flawed procedures

Question 14

How does a variable error differ from a constant error

Answer 14

Variable errors are random in nature where as constant errors follow systematic pattern

Question 15

How can an engineers behaviour be broken down

Answer 15

1. Skill based
2. Rule based
3. Knowledge based

Question 16

What are Examples of skill based behavioural errors

Answer 16

1. Action Slips
2. Environmental Capture
3. Reversion

Question 17

What is Reversion

Answer 17

Acquiring a certain pattern of behaviour, which can be very difficult to abandon or unlearn when it’s no longer necessary

Question 18

What are the types of error used in the context of visual inspection

Answer 18

Type 1 and Type 2

Question 19

What is type 1 error

Answer 19

When a good item is incorrectly identified as faulty

Question 20

What is a type 2 error

Answer 20

When a fault is overlooked

Question 21

What are the four types of violations in aircraft maintenance

Answer 21

1. Routine
2. Optimising
3. Situational
4. Exceptional

Question 22

Where are routine violations

Answer 22

Practices that have become the norm

Question 23

What are Optimising Violations

Answer 23

Entails breaking the rules for fun or personal gain, usually unrelated to the actual task

Question 24

What are situational Violations

Answer 24

These are down to circumstantial factors

Question 25

What are Exceptional Violations

Answer 25

They involve tasks or operating circumstances where violations are inevitable

Question 26

How are incidents collected and exchanged to prevent aircraft accidents

Answer 26

Mandatory Occurrence Reporting System (MORS)

Question 27

What are the basic considerations when deciding whether or not to report an incident

Answer 27

1. Did a dangerous situation occur 2. Could a dangerous situation occur if circumstances been different 3. Could a dangerous incident occur if not corrected

Question 28

How can you report safety concerns and incidents confidentially in the UK

Answer 28

Confidential Human factors Incident Reporting Program (CHIRPS)

Question 29

How does the maintenance engineering industry manage errors

Answer 29

Organisations must have their own Safety Management System (SMS)