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Safety & Human Error II
Terms in this set (35)
What is the goal of HF design when trying to maximize safety?
Design system that minimizes the frequency and severity of the aversive consequences of error
What is the most common method for improving safety within a system?
Re-design + re-evaluate system
What should great HF design do to maximize safety?
Anticipate and mitigate new errors
What is human fault tolerance?
-Continued system operation despite human error, loss, or failure
-technology corrects human errors of omission and commission
-usually for a limited amount of time
What is misplaced competence?
-Experts who are well-practiced are less likely to make mistakes and more likely to make slips
-Training only helps so much
-One action intrudes into another
Which errors are experts more likely to make? Which errors are they less likely to make?
Experts make slips, less likely to make mistakes
What cognitive skills are important when discussing 'expertise'?
What is interposition?
denial of access to harm by separating humans from the error via barrier
What is sequestration?
physically isolating the error or human from the source of harm via appropriate distance and warnings with color coded boundaries
What is an interlock?
spatial or temporal measure prohibiting exposure in place until threat has past
What is lockout?
-procedue or device that prevents improper, inadvertent, or untimely behavior w/ equipment, (machine's power switch locked in off position, maintenance worker only one with key, place tag on power switch, ID
-Prevents inadvertent activation of machine + injury to maintenance worker
What is a guide?
-Physical barriers w/in the tech that counter foreseeable misalignments, jams, damage
-Prevent human errors when trying to fix
What is a stop?
a physical barrier to prevent over-feeding a machine
What is behavior modification?
Exercises to change how ppl think + act concerning risk and safe work habits
What is redundancy?
Design should provide more than one way to accomplish a task (i.e. multiple taillights)
What are the disadvantages of redundancy?
-Complacence (reduces alertness)
-Social loafing (people exert less effort toward a goal when working in group vs. alone)
What is social loafing?
People exert less effort toward a goal when working in group vs. alone
What is a fail-safe?
Design characteristic wherein equipment failure does not increase likelihood of error or accident
What is independent confirmation?
-Seeking second (and third) opinions on 'safe' equipment, conduct, or practices
-Minimizes cognitive bias
What was unique about the Apollo 13 mission?
Know the HF issues that affected the mission before the shuttle launched.
-replacement crew was needed
-Strong oscillations led to automation engine shutdown, causing other engines to burn longer to compensate
Know the general sequence of events of the Apollo 13 lunar mission.
-Crew hears "loud bang", electricity
fluctuations, loses communication with Earth
-Damage to service module, oxygen tanks empty
-fuel cells shut down, leading to power shortage, water shortage, loss of heat, CO2 buildup
-Have to rely on Commend Module for information and help
-Moved to Lunar Module, decide to circumvent the moon
-Reentry into pacific ocean
Who composed the Apollo 13 review board and what were their conclusions as to the cause of the accident? How did they come to those particular conclusions?
-NASA and USAF personnel made up review board
-Oxygen tank 2 = damaged insulation on wires
-Stirring tanks = short-circuit
-Fire increased pressure beyond tolerance levels
-Explosion; blew off panel which damaged first antenna
-Came to these conclusions by investigating oxygen tanks and testing a replica with a formalized hypothesis
Know the long-standing changes in aeronautical safety policies and design that came about as a direct result of Apollo 13.
-Oxygen tank re-design: quantity probes (aluminum to stainless steel), supply valves (no longer exposed oxygen to wiring)
-All electrical wiring cased in stainless steel (to avoid spread of potential fire)
-Interfaces in CM, LM, SM & Mission Control re-designed (more immediate + salient feedback)
Why is US Flight 1549 particularly memorable to HF researchers and the general public?
considered most successfully emergency ditching and evacuation in aviation history
Where and when did US Flight 1549 take place?
Know the personnel in charge of piloting US Flight 1549.
-Chesley B. 'Sully' Sullenberger (captain, former fighter pilot, 29 years experience in commercial aviation)
-Jeffrey B. Skiles (first officer, 15,643 flight hours, just passed training to operate Airbus, operates the plane upon take off)
Know the general sequence of events associated with US Flight 1549.
-Birds get sucked into engines, lead to double engine failure
-Sullenberger takes on manual control and lands in Hudson River
-Safe landing and evacuation (people get onto wing rafts and stood on wings)
-Rescue efforts were fast acting
Which federal agencies investigated the events associated with UF Flight 1549? What did they conclude was the causal factor that resulted in the emergency landing?
-Federal Aviation Administration (FAA)
-National Transportation Safety Board (NTSB)
-concluded: canadian geese sucked into the engines were the main cause
What factors were identified as being crucial to the successful rescue of all US Flight 1549 passengers?
-Stellar cockpit resource management
-Fast response by ground personnel
Where and when did the Copiapό mining accident take place? How long did the ordeal last?
Copiapo, Chile in 2010
Lasted 69 days
What were some social and organizational precursors to the accident?
-Chile has poor safety record and many safety violations
-Lack of oversight
-generally dangerous environment/profession
Know the general sequence of events associated with the Chilean mining accident.
-Mine collapses and shafts caves in
-Miners caught deep underground
-Rescue efforts begin even though all available access routes are blocked
-Drill holes into ventilation shaft, medical treatment and food sent down
-Fenix Rescue Capsule sent down to collect miners
Identify HF issues associated with the collapse and rescue efforts.
-Maps were outdated
-Escape ladders were missing
What were some of the immediate and long-term effects of the Copiapό mining accident?
-Overhaul of Chile's mining regulatory agency
-Mines were shut down
-Commission on Work Safety established
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