Finals Flashcards
(244 cards)
1
Q
Twelve primary contributing factors that cause human errors and affect human performance.
A
Dirty Dozen
2
Q
Human factors that degrade people’s ability to perform effectively and safely which could lead to maintenance errors.
A
Dirty Dozen
3
Q
Were adopted by the aviation industry as a straightforward means to discuss human error in maintenance.
A
Dirty Dozen
4
Q
Maintenance-related aviation accidents occurred during what years?
A
Late 1980s and early 1990s
5
Q
Who identified twelve human factors?
A
Transport Canada
6
Q
Identified by Transport Canada
A
12 Human factors
Dirty Dozen
7
Q
Dirty Dozen:
Failure to transmit, receive or provide enough information to complete a task.
A
Lack of Communication
8
Q
Dirty Dozen:
Only 30% of verbal communication is received and understood by either side in a conversation. Others usually remember the first and last part of what you say.
A
Lack of Communication
9
Q
Dirty Dozen:
Overconfidence from repeated experience performing a task.
A
Complacency
10
Q
Dirty Dozen:
Shortage of the training, information, and/or ability to successfully perform.
A
Lack of Knowledge
11
Q
Dirty Dozen:
Avoidance of being a know-it-all
A
Lack of Knowledge
12
Q
Dirty Dozen:
Anything that draws your attention away from the task at hand.
A
Distraction
13
Q
Dirty Dozen:
The #1 cause of forgetting things, including what has or has not been done in a maintenance task.
A
Distraction
14
Q
Dirty Dozen:
Safety net: always use or refer to your checklist, go back 3 steps when proceeding after distraction.
A
Distraction
15
Q
Dirty Dozen:
Failure to work together to complete a shared goal.
A
Lack of Teamwork
16
Q
Dirty Dozen:
Lack of communication can occur.
A
Lack of Teamwork
17
Q
Dirty Dozen:
Physical or mental exhaustion threatens work performance.
A
Fatigue
18
Q
Dirty Dozen:
Not having enough people, equipment, documentation, time, parts, etc. to complete a task.
A
Lack of Resources
19
Q
Dirty Dozen:
Real or perceived forces demanding high-level job performance.
A
Pressure
20
Q
Dirty Dozen:
Failure to speak up or document concerts about instructions, orders, or the actions of others.
A
Lack of Assertiveness
21
Q
Dirty Dozen:
A physical, chemical, or emotional factor that causes physical or mental tension
A
Stress
22
Q
Dirty Dozen:
Safety net: take a break when needed, do not stress yourself more.
A
Stress
23
Q
Dirty Dozen:
Happens with a lack of alertness
A
Lack of Awareness
24
Q
Dirty Dozen:
Failure to recognize a situation, understand what it is, and predict the possible results.
A
Lack of Awareness
25
Dirty Dozen:
| Expected, yet unwritten, rules of behavior.
Norms
26
Dirty Dozen:
| Inevitable to be adapted.
Norms
27
Dirty Dozen:
| Safety net: stick to the regulations and proper procedures.
Norms
28
MEDA meaning
Maintenance Error Decision Aid
29
A structured process that is used to investigate events caused by maintenance technician and/or inspector performance.
Maintenance Error Decision Aid (MEDA)
30
Its purpose is to gather the information that is needed to carry out an event investigation.
Maintenance Error Decision Aid (MEDA)
31
It is an interview with the maintenance technician and/or inspector whose performance led to the event.
MEDA Event Investigation
32
MEDA Event Investigation finds out: (2)
1. What errors and violations occurred
| 2. The contributing factors to the errors and violations
33
From error model to ____ model
Event
34
"ERROR" investigation process to "___" investigation
EVENT
35
"___" investigation process to "EVENT" investigation
ERROR
36
Errors/Violations that are committed by the technician.
Events
37
Not all events are caused by ___.
Errors
38
Not all ___ are caused by errors.
Events
39
Anything that contributes to committing events
Contributing Factors
40
Can negatively affect how a maintenance technician and/or inspector does his/her job
Contributing Factors
41
Ranges from the smallest of things to critical decision making
Contributing Factors
42
MEDA Event Model 2
Initial MEDA Error Model
43
MEDA Event Model 3
Probabilistic MEDA Error Model
44
MEDA Event Model 4
Enhanced MEDA Error Model
45
MEDA Event Model 5
Further Enhanced MEDA Error Model
46
MEDA Event Model 6
Event Model 1 with Violation Leading Directly to a System Failure
47
MEDA Event Model 7
Event Model 2 with a Violation Causing the Technician Not to Catch an Error-Caused System Failure
48
MEDA Event Model 8
Combined Violation Model
49
MEDA Event Model 9
Final MEDA Event Model
50
Explained using the final MEDA event model
MEDA Philosophy
51
A maintenance-related event can be caused by an error, by a violation, or by an error/violation combination
MEDA Philosophy
52
Maintenance errors are not made on purpose
MEDA Philosophy
53
Maintenance errors are caused by a series of contributing factors
MEDA Philosophy
54
Violations, while intentional, are also caused by contributing factors
MEDA Philosophy
55
Most of these errors or violations contributing factors are under the control of management, therefore, can be improved so that they do not contribute to future, similar events.
MEDA Philosophy
56
Developed by Boeing in 1992
MEDA
57
Used to help address errors and eventually even violations
MEDA Investigation Process
58
MEDA Investigation Process:
| 1.
Event Occurs
59
MEDA Investigation Process:
| 2.
Investigation find that event was caused by technician/inspector performance
60
MEDA Investigation Process:
| 3.
Find the maintenance technician/inspector who did the work
61
MEDA Investigation Process:
| 4.
Interview the person
62
MEDA Investigation Process:
| 4. Objectives in interviewing the person
1. Find error/violations
2. Find contributing factors
3. Get ideas for process improvement
63
MEDA Investigation Process:
| 5. __ to get all relevant contributing factors information
Carry out follow-up interview
64
MEDA Investigation Process:
| 6. ___ to a maintenance event database
Add the result from investigation information
65
MEDA Investigation Process:
| 7.
Make process improvements
66
MEDA Investigation Process:
| 7. Make process improvements based on:
1. This event
| 2. Data from multiple events
67
MEDA Investigation Process:
| 8. ___ affected by the process improvements
Provide feedback to all employees
68
Accurate and timely reporting of relevant information related to hazards, incidents, or accidents is a fundamental activity of safety management.
Safety Reporting
69
The data used to support safety analyses are reported by multiple sources.
Safety Reporting
70
One of the best sources of data is direct reporting from?
Front-line personnel
71
Prerequisite for effective safety reporting
Personnel have been:
1. Trained
2. Encouraged to report errors and experiences
72
Things, situations, activities, or conditions can bring harm and can cause lives.
Hazard
73
Identifying ___ is one way to prevent ___
1. Hazard
| 2. Accidents
74
Safety Management is caused by _____
Safety Hazard Reporting
75
_____ is caused by Safety Hazard Reporting
Safety Management
76
To prevent hazards
Reporting hazards
77
Through safety hazard reporting the management will be able to:
1. Identify the hazard
| 2. Improve safety
78
Five Basic Characteristics of Effective Safety Reporting
1. Willingness
2. Information
3. Flexibility
4. Learning
5. Accountability
79
Characteristic:
| People are willing to report their errors and experiences
Willingness
80
Characteristic:
| Management should be a culture of willingness
Willingness
81
Characteristic:
| Related to communication and trust between the employees and the management.
Willingness
82
Characteristic:
| People are knowledgeable about the human, technical, and organizational factors that determine the safety of the system.
Information
83
Characteristic:
| Trained to report the proper risks.
Information
84
Characteristic:
| Knowledgeable enough to know if a certain event is already a hazard.
Information
85
Characteristic:
| Because you have a realistic view of the hazard you know the damage.
Information
86
Characteristic:
| People can adapt reporting when facing unusual circumstances, shifting from the established mode to a direct mode.
Flexibility
87
Characteristic:
| Allowing information to quickly reach the appropriate decision-making level.
Flexibility
88
Characteristic:
| People have the competence to draw conclusions from safety information systems.
Learning
89
Characteristic:
| The will to implement major reforms.
Learning
90
Characteristic:
| People are encouraged and rewarded for providing essential safety-related information.
Accountability
91
Characteristic:
| There is a clear line that differentiates between acceptable and unacceptable behavior.
Accountability
92
Types of Reporting
1. Online reporting
2. Hotline reporting
3. Verbal reporting
4. Hard copy reporting
93
Organizational literature proposes three characterizations of organizations, depending on how they respond to information on hazards and safety information management.
Westrum Organizational Culture
94
Westrum Organizational Culture is created by?
Ron Westrum
95
What did Ron Westrum invent?
Westrum Organizational Culture
96
Three characterizations of organizations:
1. Pathological
2. Bureaucratic
3. Generative
97
Westrum:
| Hides the information.
Pathological
98
Westrum:
| Power-oriented
Pathological
99
Westrum:
| Restrains the information
Bureaucratic
100
Westrum:
| Rule-oriented
Bureaucratic
101
Westrum:
| Many factors must be considered that's why the process is slow phased.
Bureaucratic
102
Westrum:
| Values the information.
Generative
103
Westrum:
| Goal-oriented
Generative
104
___ is characterized by the beliefs, values, biases, and their resultant behavior that are shared among members of safety, group, or organization.
Culture
105
Set of values, behaviors, and attitudes
Culture
106
Encouraging or giving confidence to the employees to report hazards.
Safety Culture
107
One of those nebulous things, like safety management.
Safety Culture
108
Behavior and performance of employees when no one is watching.
Safety Culture
109
You cannot see it or touch it. You can only see evidence or absence of its existence.
Safety Culture
110
It is not something you get or buy; it develops over time and must be maintained.
Safety Culture
111
Relies on a high degree of trust and respect between personnel and management and must therefore be created and supported at the senior management level.
Positive Safety Culture
112
Like trust, ____ takes time and effort to establish and can be easily lost.
Positive Safety Culture
113
Created by Patrick Hudson
Safety Culture Maturity Model
114
Developed back in 2000s (2003)
Safety Culture Maturity Model
115
The model specifies at which level the hazard is.
Safety Culture Maturity Model
116
The model which is increasingly informed
Safety Culture Maturity Model
117
The model which is increasing in trust and accountability
Safety Culture Maturity Model
118
Five-step progression of Safety Culture Maturity Model
1. Pathological
2. Reactive
3. Calculative
4. Proactive
5. Generative
119
Maturity Model:
| Who cares as long as we are not caught?
Pathological
120
Maturity Model:
| No care safety culture
Pathological
121
Maturity Model:
| "Who cares" approach
Pathological
122
Maturity Model:
| Business is top priority
Pathological
123
Maturity Model:
| Also known as emerging
Pathological
124
Maturity Model:
| Safety is important, we do a lot every time we have an accident
Reactive
125
Maturity Model:
| Safety is regarded as a burden
Reactive
126
Maturity Model:
| Fix to blame approach
Reactive
127
Maturity Model:
| They see accidents are caused by employees
Reactive
128
Maturity Model:
| Also known as managing
Reactive
129
Maturity Model:
| There are systems in place to manage all hazards
Calculative
130
Maturity Model:
| Many audits are collective which will be used to improve the system.
Calculative
131
Maturity Model:
| The mindset of the management is the system they have is already enough.
Calculative
132
Maturity Model:
| Complacency
Calculative
133
Maturity Model:
| Everything is cased by what happened in the past
Calculative
134
Maturity Model:
| Safety is not the core value
Calculative
135
Maturity Model:
| Also known as involving
Calculative
136
Maturity Model:
| Safety leadership and values drive continuous improvement.
Proactive
137
Maturity Model:
| They aim to anticipate the problems before it happens.
Proactive
138
Maturity Model:
| They consider factors that might go wrong in the future
Proactive
139
Maturity Model:
| They act before future mistakes may happen.
Proactive
140
Maturity Model:
| Safety is top priority
Proactive
141
Maturity Model:
| They use bad news to further improve the system.
Proactive
142
Maturity Model:
| Safety is the core value
Proactive
143
Maturity Model:
| Also known as cooperating
Proactive
144
Maturity Model:
| Generate High-Reliability Organization (HRO), Health, Safety, and Environment (HSE)
Generative
145
Maturity Model:
| That is how we do business around here.
Generative
146
Maturity Model:
| They use failure to improve, not to blame
Generative
147
Maturity Model:
| Never think that their system is never enough.
Generative
148
Maturity Model:
| Despite all their efforts, they believe that accidents may and will occur.
Generative
149
Maturity Model:
| Safety environment is a top priority. (Core Value)
Generative
150
Maturity Model:
| Safety is not driven by numbers, but by a core value that safety is an integral part of the operation.
Generative
151
Maturity Model:
| Safety improvement is investment, not a cost
Generative
152
Maturity Model:
| They have outstanding communication with their workforce.
Generative
153
Maturity Model:
| Also known as continually improving
Generative
154
If "A" exists, then "B" will occur.
Cause-In-Fact
155
If "A" exists, the the the probability of "b" occurring increases.
Probabilistic
156
There are few "cause-in-fact" occurrences in the ____ world
Maintenance technician/inspector's
157
MEDA Event Model:
Figure 1:
Contributing factors -> error:
Almost all causes are
Probabilistic
158
MEDA Event Model:
Figure 1:
Error -> event:
it is possible to have some
Cause-In-Fact
159
MEDA Event Model:
Figure 3:
There is a probabilistic relationship between:
1. Contributing factors and an error
| 2. An error and an event
160
MEDA Event Model:
| Figure 4: There are ___ contributing factors to each error
3 to 5
161
MEDA Event Model:
| Figure 5: There are ____ to the contributing factors
Contributing factors
162
MEDA Event Model:
Figure 5:
Ask why how many times?
5 times
163
MEDA Event Model:
| Two ways that a violation can contribute to an event
Figure 6 and 7
164
MEDA Event Model:
Figure 6:
The maintenance technician does not use a torque wrench when called out in the maintenance manual
Violation
165
MEDA Event Model:
Figure 6:
He under torques the bolt
System Failure
166
MEDA Event Model:
Figure 6:
Air turn back
Event
167
```
MEDA Event Model:
Figure 6:
Reasons for not using torque wrench:
- There was no torque wrench
- Work norm to not use a torque
```
Contributing factors
168
MEDA Event Model:
Figure 7:
Failure to carry out an operational check
Violation
169
MEDA Event Model:
Figure 7:
Failure to carry out an operational check at the ___ of the procedure would catch an error.
End
170
MEDA Event Model:
| If the technician failed and then the inspector failed the system an event will occur
Figure 8: Combined Violation Model
171
MEDA Event Model:
| Summarization of causational events
Figure 9: Final MEDA Event Model
172
MEDA Event Model:
| Interprets the theoretical bases of MEDA
Figure 9: Final MEDA Event Model
173
MEDA Event Model:
| Final event causation model that includes errors and violations
Figure 9: Final MEDA Event Model
174
MEDA was developed by?
Boeing
175
When was MEDA developed?
1992
176
The potential outcome of the hazard.
Consequence
177
A potential source of damage.
Hazard
178
Projected likelihood and severity of the consequences or outcome from an existing hazard or situation.
Safety Risk
179
While the outcome may be an accident, intermediate unsafe event/consequences may be identified as – the most credible outcome.
Safety Risk
180
Addresses, analyses, and mitigates all risks.
Risk Management
181
Reduces the hazard at an acceptable level/
Risk Management
182
The likelihood of how often an unsafe event might occur.
Safety Risk Probability
183
One way to determine the probability of hazards.
Records
184
How many people are likely to get involved with this hazard.
Safety Risk Probability
185
Probability:
| Likely to occur many times
Frequent
186
Probability:
| Has occurred frequently
Frequent
187
Probability:
| Value of 5
Frequent
188
Probability:
| Likely to occur sometimes
Occasional
189
Probability:
| Has occurred infrequently
Occasional
190
Probability:
| Value of 4
Occasional
191
Probability:
| Unlikely to occur, but possible
Remote
192
Probability:
| Has occurred rarely
Remote
193
Probability:
| Value of 3
Remote
194
Probability:
| Very unlikely to occur
Improbable
195
Probability:
| Not known to have occurred
Improbable
196
Probability:
| Value of 2
Improbable
197
Probability:
| Almost inconceivable that the event will occur
Extremely Improbable
198
Probability:
| Value of 1
Extremely Improbable
199
After knowing the probability, you must then assess or identify the ___
Safety Risk Severity
200
The extent of harm that might reasonably occur as a consequence or outcome of the identified hazard.
Safety Risk Severity
201
The extent of the damage
Safety Risk Severity
202
The extend of the hazard
Safety Risk Severity
203
The environmental impact which can be identified using questions.
Safety Risk Severity
204
Severity:
| Equipment destroyed
Catastrophic
205
Severity:
| Multiple deaths
Catastrophic
206
Severity:
| Value of A
Catastrophic
207
Severity:
A large reduction is safety margins, physical distress, or a workload such that the operators cannot be relied upon to perform their tasks accurately or completely.
Hazardous
208
Severity:
| Serious injury
Hazardous
209
Severity:
| Major equipment damage
Hazardous
210
Severity:
| Value of B
Hazardous
211
Severity:
A significant reduction in safety margins, a reduction in the ability of the operators to cope with adverse operating conditions because of an increase in workload or because of condition impairing their efficiency.
Major
212
Severity:
| Serious incident
Major
213
Severity:
| Injury to persons
Major
214
Severity:
| Value of C
Major
215
Severity:
| Nuisance
Minor
216
Severity:
| Operating limitations
Minor
217
Severity:
| Use of emergency procedures
Minor
218
Severity:
| Minor incident
Minor
219
Severity:
| Value of D
Minor
220
Severity:
| Few consequences
Negligible
221
Severity:
| Value of E
Negligible
222
Also known as Safety Risk Index or Risk Index
Safety Risk Assessment Matrix
223
Combination of the result of the probability and the assessment of the severity of the hazard.
Safety Risk Assessment Matrix
224
Safety Risk Tolerability Matrix:
| 3 Regions:
- Intolerable region
- Tolerable region
- Acceptable region
225
Tolerability Matrix:
| High-risk
Intolerable
226
Tolerability Matrix:
| Unacceptable under any circumstances
Intolerable
227
Tolerability Matrix:
| The probability and/or severity of the consequences and the damaging potential of the hazard is a threat to safety.
Intolerable
228
Tolerability Matrix:
| Immediate mitigation is required
Intolerable
229
Tolerability Matrix:
| The risk is unacceptable at any level
Intolerable
230
Tolerability Matrix:
| The risk is acceptable but further analysis is required.
Tolerable
231
Tolerability Matrix:
| Medium risk
Tolerable
232
Tolerability Matrix:
| Acceptable provided that acceptable mitigation strategies are implemented.
Tolerable
233
Tolerability Matrix:
| Low risk
Acceptable
234
Tolerability Matrix:
| The risk is acceptable as it currently stands.
Acceptable
235
Tolerability Matrix:
| Acceptable as they currently stand.
Acceptable
236
Overall Management
Safety Risk Management
237
The assessment and mitigation of safety risks.
Safety Risk Management
238
It assesses the risks associated with the identified hazards.
Safety Risk Management
239
Develops and implements effective and appropriate mitigations.
Safety Risk Management
240
A key component of the safety management process at both the State and product/service provider level.
Safety Risk Management
241
HIRA meaning
Hazard Identification Risk Assessment
242
Probability:
| 5 Safety Risk Probability
- Frequent
- Occasional
- Remote
- Improbable
- Extremely Improbable
243
Severity:
| 5 Safety Risk Severity
- Catastrophic
- Hazardous
- Major
- Minor
- Negligible
244
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