Lecture 4 - Human Error

Question 1

Unintentional deviation of failure

Answer 1

Error

Question 2

Intentional failures

Answer 2

Violation

Question 3

Failure of a planned action to be completed as intended

Answer 3

Error

Question 4

– Occur at the level of the frontline operator

– Effects are felt almost immediately.

Answer 4

Active failures

Question 5

– Tend to be removed from the direct operator control

Answer 5

Latent conditions

Question 6

2 Approach WHY DO ERRORS HAPPEN ?

Answer 6

Person approach

System approach

Question 7

Blame the individual for forgetfulness, inattention, weakness

Answer 7

Person approach

Question 8

Multiple faults that occur together in an unanticipated interaction create chain of events in which faults grow and evolve.

Answer 8

System approach

Question 9

It is a portion of a task is skipped

Answer 9

Omission

Question 10

Task is performed incorrectly

Answer 10

Commission

Question 11

Task that should not have been performed, as it diverts attention from the system

Answer 11

Extraneous act

Question 12

Task is performed out of sequence

Answer 12

Sequential act

Question 13

Task performed too early, too late, or outside of time allowed

Answer 13

Time error

Question 14

What are the 3 stages of cognitive processing for tasks?

Answer 14

1) Planning
2) Storage
3) Execution

Question 15

Under 3 stages of Cognitive Processing for Tasks where a goal is identified and a sequence of actions is selected to reach the goal

Answer 15

Planning

Question 16

Under 3 stages of Cognitive Processing for Tasks where the selected plan is stored in memory until it is appropriate to carry it out

Answer 16

Storage

Question 17

Under 3 stages of Cognitive Processing for Tasks where the plan is implemented by the process of carrying out the actions specified by the plan

Answer 17

Execution

Question 18

What are the 3 Form of Error?

Answer 18

1. Slips: execution stage
2. Lapses:: storage stage
3. Mistakes: planning stage

Question 19

incorrect execution of a planned action

example: miss keyed command

Answer 19

Slips

Question 20

» incorrect omission of a stored, planned action
» examples: skipping a step on a checklist, forgetting to
restore normal valve settings after maintenance

Answer 20

lapses

Question 21

» the plan is not suitable for achieving the desired goal

Answer 21

mistakes

Question 22

TRUE or FALSE.

Slips and lapses occur when the task is very unfamiliar and requires little thought.

Answer 22

FALSE

Question 23

TRUE or FALSE.

Slips and lapses occur when people confuse two similar tasks

Answer 23

TRUE

Question 24

TRUE or FALSE.

Slips and lapses occur when the main part is missed but the finer details are done

Answer 24

FALSE

Question 25

TRUE or FALSE. | Slips and lapses occur when tasks are too complicated and long-winded

Answer 25

TRUE

Question 26

TRUE or FALSE. | Slips and lapses occur when there are distractions and interruptions.

Answer 26

TRUE

Question 27

TRUE or FALSE. | Mistakes occur when doing few things at the same time.

Answer 27

FALSE

Question 28

TRUE or FALSE. | Mistakes occur when doing too many complex tasks at once.

Answer 28

TRUE

Question 29

TRUE or FALSE. | Mistakes occur when time pressures.

Answer 29

TRUE

Question 30

What does GEMS mean?

Answer 30

Generic Error-Modeling System

Question 31

an attempt to understand the origins of human error

Answer 31

Generic Error-Modeling System

Question 32

What are the 3 levels of cognitive task processing identified by GEMS?

Answer 32

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

Question 33

Levels of cognitive task processing that is familiar, automatic procedural tasks.

Answer 33

Skill-based

Question 34

Levels of cognitive task processing that the tasks approached by pattern-matching from a set of internal problem-solving rules

Answer 34

Rule-based

Question 35

Levels of cognitive task processing that the tasks approached by reasoning from first principles

Answer 35

Knowledge-based

Question 36

Errors that we experience, without intending to, you do the wrong thing.

Answer 36

Slip

Question 37

Errors that we experience, without intending to, you fail to do what we meant to do.

Answer 37

Lapses

Question 38

Errors that we experience, without intending to, you mishandle or blunder an action or word.

Answer 38

Fumble

Question 39

In addressing human error, general approach: error-avoidance rather than error-tolerance or error-tolerance rather than error-avoidance?

Answer 39

error-tolerance rather than error-avoidance

Question 40

TRUE or FALSE. | Automation is the cure for human error

Answer 40

FALSE

Question 41

It is the ability to withstand.

Answer 41

Robustness

Question 42

What does S.T.A.R means when self-checking?

Answer 42

Stop Think Act Review

Question 43

Best way to address human error is tolerance or avoidance?

Answer 43

Tolerance

Question 44

“to err is _____"

Answer 44

Human