Upgrade to remove ads
Safety and Human Error II
Terms in this set (26)
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?
Most Common Strategy
•Re-design + re-evaluate system
-Good for addressing past problems
-Useless for preventing future/unfamiliar errors
•Great design should anticipate and
mitigate new errors
•Need for HF research
-All 3 types discussed last week
»New ≠ old - problems
»New = new + new problem
What should great HF design do to maximize safety?
Anticipate and mitigate new errors
What is human fault tolerance?
Goal: A Tolerant System
•Human fault tolerance
-Continued system operation
despite human error, loss, or
-Usually for a limited
amount of time
-Technology can correct
human errors of omission or
What is interposition?
•Denial of access to harm or hazard
•Separating humans from the error via a
•Protect ppl from harm
•Protect tech from damage
•Be aware; can be
What is sequestration?
•Physically isolate the
error or source of harm
•Warnings w/ color-coded
-Protective gear necessary
-Under no circumstance
What is behavior modification?
-What ppl do
-Exercises to change how ppl think + act concerning risk and safe work habits
-As punishment is ineffective
What is redundancy?
•Design should provide more than
one way to accomplish a task
•Especially in life-or-death systems
What is a fail-safe?
•Design characteristic wherein
equipment failure does not increase
likelihood of error or accident
-Dead Man's Switch
•Automatically operated in case operator
•Requires application of pressure
-w/out = operation stops safely
•Allows for safe pull-ove
What is independent confirmation?
•Seeking second (and third) opinions on
'safe' equipment, conduct, or practices
•Helps minimize cognitive biases
•Gives credulity to findings when
-USDA testing for bovine spongiform
•7 month period of inaction
•Tested by 1 set of scientists
-Improper handling of sampl
What was unique about the Apollo 13 mission?
•Objective: 3rd manned mission to the moon
-Fra Mauro formation
•April 11, 1970 - April 17, 1970
•Aborted lunar mission
•Safe return of crew
Know the HF issues that affected the mission before the shuttle launched.
Apollo 13: Crew Issues on the Ground
-Crew + Backup Crew train
-Member of Backup Crew
•Exposure to rubella
•Medical history analysis
•Mattingly ≠ immune
-Replaced with John L.
Know the general sequence of events of the Apollo 13 lunar mission.
-Crew hears "loud bang", electricity fluctuations, loses communication with Earth
-Initial assessment: rogue meteroid struck the lunar module
-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 Command 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?
•Apollo 13 Review Board
-Determine cause of accident
-NASA & USAF personnel
-Notable member: Neil Armstrong
-Investigated oxygen tank
•Installation + maintenance records
•Visited contractor site where manufactured
•Formed hypothesis + tested a replica in a vacuum chamber
•Test confirmed theory
-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
•Aluminum to stainless steel
•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?
1/15/09 Hudson River
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.
•Double engine failure
•Sullenberger takes over manual control
•Contacts ATC control for emergency landing at airport
-Permission granted, all ground flights halted
•Sullenberger realizes insufficient power to reach airports
•Passes only 900 ft. above the George Washington Bridge
•Lands in Hudson River
-B/w Manhattan, NY + Weehawken, NJ
-Sullenberger purposefully aims for area near high boat traffic
•Safe landing, but still dangerous
•Possibility of drowning
•Panicked passenger opened rear door
•Stood on wings
•Jumped into the water
•Commercial ferries first to
•US Coast Guard
•NJ State Police helicopter
Which federal agencies investigated the events associated with US Flight 1549? What did they conclude was the causal factor that resulted in the emergency landing?
-Federal Aviation Administration (FAA)
-National Transportation Safety Board
-Experiments in simulation
•Safe landings: 8/15
•Conclusion: Canadian geese
-In the egg
What factors were identified as being crucial to the successful rescue of all US Flight 1549 passengers?
•What went right?
•More than mandated
-Good weather conditions
-Stellar cockpit resource
-Fast response by ground
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. underground = inhospitable
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 regarding mining safety?
-Overhaul of Chile's mining regulatory agency
-Mines were shut down
-Commission on Work Safety established
•Overhaul of Chile's mining regulatory
•18 mines immediately shut, 300 put on notice
•Commission on Work Safety
-Report on incident
•30 recommendations for safety improvements
-3 year investigation
-No charges filed
•San Esteban Mining Company
THIS SET IS OFTEN IN FOLDERS WITH...
Safety & Human Error I
Safety & Human Error II
YOU MIGHT ALSO LIKE...
102 SAFETY FUNDAMENTALS
Safety Program Management - Test 1
OTHER SETS BY THIS CREATOR
abnormal psychology final exam
Abnormal Exam 3
Abnormal Psych exam 2
Social Psychology chapter 8