Chapter 15 - Cultural Influences on Error

Question 1

Who is responsible for flight safety?

Answer 1

Everyone

Question 2

What is the most significant piece of equipment introduced to improve safety and when was it introduced?

Answer 2

Ground Proximity Warning System (GPWS)

1980

Question 3

The Aviation Authority is an “open culture”. What are the key characteristics of an open culture?

Answer 3

All levels of the organisation play a part in ensuring safety.

Mistakes can be reported without risk of sanction, which allows others to know about them and create preventative measures.

Question 4

What is a closed culture?

Answer 4

One which an organisation would be reluctant to release information/reports on errors/threats/undesired aircraft states.

Question 5

What factors promote a good safety culture?

Answer 5

Leadership
Commitment
Setting good examples

Question 6

What is meant by an error chain?

Answer 6

Errors are cumulative and so subsequent errors can form an error chain. Breaking one link, or highlighting and fixing and error, can break an error chain.

Question 7

What are the components of a positive safety culture?

Answer 7

A just culture
A reporting culture
An informed culture
A learning culture 
A flexible culture

Question 8

What does TEM stand for?

Answer 8

Threat & Error Management

Question 9

What are the 3 components, with definitions, of Threat & Error management?

Answer 9

Threats - events beyond the influence of the crew

Errors - Actions or inactions by flight crew.

Undesired Aircraft State (UAS) - Crew induced aircraft configuration deviation

Question 10

How do threats develop into an un-safe outcome?

Answer 10

Threats when undefended become errors.
Errors when uncorrected become a UAS.
A UAS when not handled correctly will become an un-safe outcome.

Question 11

What is the acronym for the different types of threats and what are they?

Answer 11

LEO

Latent threats - not obvious/unseen, eg. Poor equipment design(unseen), quick turn around times.

Environmental threats - Weather, Terrain, ATC.

Organisational threats - Operations, Documentation Aircraft/cabin design (seen)

Question 12

What is the acronym for the different types of errors and what are they?

Answer 12

PAC

Procedural errors - Caused by the interaction between a pilot and a procedure, such as an SOP.

Aircraft handling errors - Caused by an interaction between a pilot and the aircraft through various controls.

Communication errors - Caused by an interaction between a pilot and other people such as ATC and ground crew.

Question 13

What is the acronym for the different types of UAS and what are they?

Answer 13

AGI

Aircraft heading - Vertical and/or lateral and/or speed deviation.

Ground navigation - eg Incorrect taxi holding position or taxiway.

Incorrect system configuration - Wrong automation mode configuration, wrong flap configuration etc.

Question 14

What is the ATM threat and error management strategy?

Answer 14

Avoid threats

Trap errors

Mitigate UASs

All so that an incident or accident does not occur.

Question 15

What three things makes up a persons personal competency as a pilot?

Answer 15

KSA

Knowledge - The store of professional knowledge you acquire, enabling you to recognise, understand and deal with new situations.

Skills - Operating and interpersonal skills you need to operate a commercial airliner in a multi-crew environment.

Attitude - Your mental approach to the job and the education and training involved.

Question 16

What are the 8 core competencies of a pilot?

Answer 16

CAALPAWS

1) Communication
2) Aircraft flight path management (manual)
3) Aircraft flight path management (automatic)
4) Leadership & teamwork
5) Problem solving and decision making
6) Application of procedures
7) Workload management
8) Situational awareness

Question 17

What can we do to completely avoid human error?

Answer 17

We can’t completely avoid human error. It is inevitable.

Question 18

What is an informed culture?

Answer 18

Those who manage and operate the system have current knowledge about the human, technical, organisational and environmental factors that determine the safety of the system as a whole.

Question 19

What is a reporting culture?

Answer 19

An organisation climate in which people are prepared to report their errors and near misses.

Question 20

What is a just culture?

Answer 20

An atmosphere of trust in which people are encouraged for providing essential safety related information; but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviours.

Question 21

What is a flexible culture?

Answer 21

A culture in which an organisation is able to reconfigure itself in the face of high tempo operations or certain kinds of danger - often shifting from the conventional hierarchical to flatter mode.

Question 22

What is a learning culture?

Answer 22

An organisation must possess the willingness and the competence to draw the right conclusions from its safety information system and the will to implement major reforms.

Question 23

What are the 5 components of the SHELL model?

Answer 23

Software (information)
Hardware (electrical units and equipment)
Environment (weather/atmosphere inside or outside of the cockpit)
Liveware (pilot)
Liveware (other people)

Question 24

What can cause errors in the liveware to software interaction?

Answer 24

Poorly indexed or unclear information layout/operating documents or odd sequence of drills causing.

Question 25

What can cause errors in the liveware to environment interaction?

Answer 25

Things like noise, temperature, lighting and weather. More latent things like stress and organisational pressure also come into this category.

Question 26

What can cause errors in the liveware to hardware interactrion?

Answer 26

Poor ergonomics, such as a 3 point altimeter compared to a digital display.

Question 27

What is the increased error rate associated with a 3 point altimeter?

Answer 27

It is 3 times more difficult to read and increases error rate by 20%