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Safety & Human Error I
Terms in this set (56)
Senders & Moray's 3 part definition of human error?
operator's unintended action
pushed the task/system beyond its acceptable
What is the difference between operator error and design error?
operator error is system failures where human is entirely at fault
design error is system malfunction or failure originating from the system's design aspect
Know the five perspectives on what causes human error.
-imposing task demands that exceed human capacity limits
-general situation characteristic that predisposes people to male errors
-abilities and attitudes
What are error-likely situations?
What two human individual differences are generally reliable indicators of the likelihood of system error?
abilities and attitudes
-susceptibility to stress
What is the 'Garbage-In/Garbage-Out' Principle?
Know the four kinds of error taxonomies.
What is the difference between an error of omission and an error of commission?
error of omission is the operator fails to perform a required action
error of commission is the operator performed inappropriate action
What is the difference between a timing error and a sequence error?
timing error is the action taken at inappropriate time in task sequence
sequence error is the actions taken in improper order to accomplish task goal
What is the difference between a selection error and a quantitative error?
selection error is operator knows appropriate step to take and manipulates the wrong control
quantitative erros: manipulates correct control to an inappropriate degree
What a pilot induced oscillations and what type of error are they?
What is the difference between recoverable and unrecoverable errors?
unrecoverable errors: system failure = inescapable
recoverable errors: correction = possible
goal: minimize adverse outcomes
-good HF design can facilitate effective recovery
How can HF help to mitigate the effects of recoverable errors?
Know the four kinds of human-initiated system failures.
For the processing classification taxonomy of error, know the types of errors that can be committed and their corresponding stage (if any) in the 3 Stage Model of Information Processing.
3 Stage Model
Failures in sensory or perceptual processes (Perceptual Stage)
Failures to effectively translate perception into action (Cognitive Stage)
Failures in the selection and execution of physical responses (Action Stage)
Ineffective sharing of information amongst team members
What is the difference between a mistake and a slip?
Error in planning an action
Did something unplanned; no intention
Error in executing an action
Did something planned, but not as intended
Know Reason's taxonomy of behavior and which stages produce either mistakes or slips.
Model of behavior
Degree of conscious control applied by operator to actions
Skill-based = slips
Rule-based + knowledge-based = mistakes
What is the difference between routine and exceptional violations? Which type of violation is more easily corrected by the safety measures of a system and why?
Occur on regular basis
System has more tolerance for correcting them
More difficult to correct the system
What is reliability testing?
What is human reliability testing? Know some examples of the factors that human reliability tests evaluate.
Human reliability testing
Use machine reliability testing as basis
Statistical analysis of dependability of human component
Combination of factors to assess accident likelihood
Why is it a good idea to combine both reliability testing and human reliability testing when assessing the overall system?
Combination of reliability testing + human reliability testing
General conceptualization of system performance, safety, and risk
Know examples of the criteria for both technology and humans that are assessed when determining safety certification of a system. Who generally determined such criteria and when should they be tested?
Tolerance , calibration of hardware
Speed, accuracy, calibration of software
Experience w/ task
Usually established by experts
Should also be periodically reviewed
Ideally assessed before each task/performance
Example: Flight check list
What are the three major types of research used to test safety considerations?
# of errors/accidents
Interviews with SMEs
Subject matter experts
Accounts of performance in the field
Or, analyze case studies
What type of perspective should HF professionals adopt when assessing the meaning of 'failure'?
Learning from failure
Failure must be seen as normal, though rare, occurrence
Know some of the reasons why unthinkingly and automatically punishing an operator for a system failure is counterproductive and detrimental to safety.
Fosters false belief that fault is w/ individual alone
Individual = part of larger interdependent system
Conditions ppl to conceal mistakes
Rather than learn
To avoid litigation/culpability
Refrain from submitting safety info to oversight agencies
Refrain from reporting incidents
What is a rehabilitative effect?
Fosters false belief that all accidents are preventable
Not a natural (though rare) outcome of system
Therefore, no rehabilitative effect
Punishment does not increase safety
What is a vicarious learning effect?
No vicarious learning effect
Learning by example/fear of punishment
What is accountability?
Implicit or explicit expectation to justify beliefs or actions to others
Fundamental element of social interaction
What is hindsight bias?
Cognitive tendency (after an event has occurred) to perceive that event as having been predictable despite no objective basis on which to base the claim
Why was the Titanic so unique as a ship/system?
Royal Mail Steamer
At launch, largest moving object in history
How qualified was E. J. Smith to fulfill the role of captain of the Titanic and why?
One of the most experienced captains in the world
What were some important HF issues related to Titanic's size?
One of the most experienced captains in the world
Know the general sequence of events regarding the Titanic disaster. [No need to go minute by minute, just a general understanding.]
/12/1912 - 4/14/1912
S.S. Californian issues ice warning to Titanic
10-12 miles away
Titanic's answer: "Shut up, I am busy"
Californian's wireless operator (Cyril Evans) shuts off his wireless system
Ineffective evasive maneuvers taken
Slow + turn
Hard to starboard
Engines full reverse
Strikes iceberg on starboard side
Six narrow openings below water line
12-13 sq. ft.
No direct address system
Stewards knocking door to door
Wireless distress signals
Indecision sets in
Never gives abandon ship
Does not organize crew or convey information
Ambiguous or impractical orders
Women + Children First
First (Murdoch) vs. Only (Lightoller)
500 vacant seats
Most passengers + crew didn't know of sinking
2:20AM (40+ min post-collision)
2:20AM - 4:10AM
Survivors adrift in the water
4:10AM - 9:15AM
Carpathia begins loading survivors
Full-steamed; great risk
More boats arrive to no avail
No remaining survivors
Start to pick up bodies
How many people died as a result of the sinking of the Titanic?
What were the subjective responses of the public with regard to the sinking?
Public outcry against industry + government
Public outpouring of good will to survivors + glorification of victims
Know the cognitive and psychosocial factors that contributed to the social environment surrounding the Titanic's construction and operation.
Reputation only after sunk
Disregard of ice warnings
What is closed-mindedness?
Tendency to be unreceptive of new ideas or arguments
Know the deficiencies in the safety practices aboard Titanic that contributed to its sinking.
Failures in Leadership
No formal evacuation strategy
No formal drill or practice
No public address system
Locked gates (myth-ish)
-Complying w/ American immigration laws
-Each class had access to life boat stations
-Unlocked after most lifeboats had launched
Crew reluctant, didn't think sinking
Know the social factors that influenced the different survival rates among the victims of the tragedy.
Class = most important factor
Most survivors = 1st class passengers
Less than 1/3 of steerage survived
Worst survival rate: crew
"Women and Children First" Policy
Best survival rate: women
So few children
Given priority in lifeboats
Informal code of conduct
Not formal mandate
HMS Birkenhead (1852)
Know the different design aspects of the Titanic's structure and functioning that contributed to its sinking.
Protection against ice
From the bridge
Individually or collectively
Compartment = NOT watertight
Water could spill from one to another
Scraped past watertight doors
Head-on might have been all right
Lookouts were supposed to have them
May have been of little use given conditions
16 boats + 4 'collapsibles'
Capacity: 1,178 ppl
Enough for 1/3
What were the main findings of the governmental inquiries launched as a result of the Titanic's sinking?
British & American inquiries
Outdated + inadequate
Improperly loaded + crewed
Captain Smith failed to heed ice warnings
Cause: dangerous area, speed = too high
No charge of negligence or unsafe practices
After all, ship + crew did comply w/ regulations
Deemed Act of God
Know the four main changes in safety standards and practice that came about as a direct result of the sinking of the Titanic.
Formal maritime laws
Adequate lifeboats for all souls aboard
Mandated lifeboat drills and inspections
Red rockets = distress call
International Convention for the Safety of Life at Sea
Radio Act of 1912 (US)
International Ice Patrol
When and where did the Tenerife Air Disaster take place?
Tenerife Island of the Canary Islands (West African coast)
Why is the Tenerife Air Disaster particularly memorable to HF researchers and the general public?
Deadliest plane crash in world history
Know the general sequence of events regarding the Tenerife Air Disaster. [Again, no need to go minute by minute, just a general understanding.]
Bomb goes off in Las Palmas airport
All flights re-directed to Tenerife airport (70 km away)
KLM and Pan Am land and taxi for a while
KLM stops to deplane and refuel, causing further delay
Heavy fog rolls in, visibility drops to 300 feet
KLM instructed to taxi down the runway, and Pan Am follows a few hundred feet behind
KLM requests permission to take off, and is given permission to prepare only
KLM is instructed to make a u-turn at the end of the runway and Pan Am instructed to turn off on the "third taxiway
Pan Am indicates that they cannot see taxiway 3 and the instructions from the tower are unclear
Visibility rises to 700 feet
Pan Am passes taxiway 3
KLM requests permission to take off and are denied
KLM takes off anyway
Pan Am tries to turn onto taxiway 4
KLM and Pan Am see one another
KLM tries to pull up
How many people died as a result of the Tenerife Air Disaster?
No survivors from KLM
61 survivors with injuries from Pan Am
Know the factors identified as contributors to the collision by the international inquiry.
What did the international inquiry identify as the primary cause of the Tenerife Air Disaster?
The crash was the direct result of the KLM Captain's decision to take off without permission
Know the long-standing changes in aviation safety policies that came about as a direct result of the Tenerife Air Disaster.
Blurring of the hierarchical lines among pilots and co-pilots
Calibrating decision making relative to a group consensus, and NOT one person
Acknowledging the different and valuable experiences of co-pilots
Captains' decisions can be overturned
Know the general sequence of events of the Iroquois Theatre Fire. [Again, no need to go minute by minute, just a general understanding.]
Malfunctioning spotlight sparks
Catch in muslin stage curtain
Stage hands attempts to extinguish
Flame retardant powder
Fire continues climbing curtain
Stage manager attempts to activate back-up system
People begin to panic
Eddie Foy takes stage
Tries to calm
Stayed to very end
Attempts to evacuate
Panic, crush, trampling
Thought windows were doors
Went down dead ends
Not clearly marked
Fire exits hidden behind curtains
Locked w/ unfamiliar mechanism
Opened by brute force
Cold air made it worse
Cyclonic blast; Fireball
Right into orchestra crowd
Some opened inwards
Became jammed in the crush
Passing railroad worker
Unfinished fire escapes
Crawl to adjoining building
Students extended ladders, boards
Most survivors landed on the dead
Theatre equipped w/ no fire alarm or telephone
Fire dept alerted
Running stage hand
Firefighters activated call box on the way
How many people was the theatre designed to hold safely? How many people were in attendance that day? Know the demographic characteristics of the audience.
Capacity: 1,602 ppl
2,100 - 2,200
500+ ppl over capacity
Blocking aisles + exits
How many people died as the result of the Iroquois Theatre Fire?
Over 600 dead
What were some appropriate fire-prevention safety measures in place at the theatre that day?
Did have some safety equipment
Know the substandard or missing design elements of the theatre that contributed to fire-related loss of life.
BEFORE THE FIRE
One entrance, exit, staircase for guests
Violated established Chicago fire ordinances
Inadequate number of exits
Absence of stage draft shaft
Structure to funnel fire up and away from audience areas
Connections for water sources
Know the deficient safety practices that contributed to the Iroquois Theatre Fire.
Disregarded input by experts
Fire inspectors bribed
No practice of evacuation or operation of equipment
Refused to open locked doors
Doors b/w floors locked to prevent taking seats
Not on day (sold out)
Know the long-standing changes in American high-occupancy, in-door events/venues that came about as a direct result of the Iroquois Theatre Fire.
Widespread implementation of crash bar
No fine motor control required
Ironically developed after Victoria Hall disaster
Asbestos curtain always in place except during show
All doors must open in direction of egress
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