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19 Cards in this Set
- Front
- Back
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Looking at Reasons Swiss cheese model, what are three ways to decrease accidents? |
Incorporating redundancy and/or checklists (add cheese slices). Properly designing systems (reduce holes in the cheese). Alerting personnel when several errors occur (alert when several holes in the cheese line up). |
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Define human error. |
Any deviance from appropriate behavior. |
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Human error is blamed for what percent of industrial accidents? |
75-95% |
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What is a deliberate violation? |
Cases where people intentionally violate procedures and regulations even though there is a risk of harm. Can be routine because ignoring procedures is common place. Errors are based in an organization or society. i.e. organizations not “walking the walk” will bleed into employees. Cultural thing. |
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What are causes of human error? |
Design requires humans to perform task they are not suited for. Interruptions are not accounted for. Rationalizing warning signals. Information overload without proper filtering. Social pressure, time, and economic considerations lessen the likelihood that pre-accident issues are resolved. |
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What are slips? |
Intended action is replaced by another. Occurs subconsciously, particularly to experts or the highly skilled. |
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What are the two subcategories of slips? |
Memory lapses. Action based. |
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What are memory lapses? |
Failure to remember to perform an action or evaluate the result of an action. |
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What are action based slips? |
Incorrect action performed. |
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What are three examples of action based slips? |
Capture slip. Description-similarity slip. Mode-error slip. |
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What is capture slip? |
Instead of performing an intended action, a more familiar or recently enacted action is performed. |
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What is description-similarity slip? |
Instead of acting on an intended object, a similar object is acted upon. |
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What is mode-error slip? |
Control meaning changes in different states (modes), and the user incorrectly assumes the mode. |
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What are mistakes? |
Actions contribute to the wrong goal/plan or a faulty goal achievement assessment occurs. |
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What are the three forms that rule base mistakes occur in? |
An appropriate rule applied to a poorly interpreted situation. Applied rule is correct, but falls short due to incomplete knowledge of situation requirements. Faulty outcome evaluation. |
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What do knowledge base mistakes involve? |
An incorrect assessment due to lack of knowledge which results in an incorrect action. |
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What do memory lapses results from? |
A failure to remember goal/plan setting or previous evaluation of results. |
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What are additional ways errors can be reduced? |
Checklists/knowledge in the world. Report and gather data on errors. Poka Yoke. Increased salience of proposed action outcome and allow reversal of action. Sensibility checks. Resilience engineering. |
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True or false: human error is often the root cause of accidents. |
False |
