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5.1 - Coggle Diagram

- - - - Human error is the primary cause of accidents
      - Automated systems (when working properly!) can produce more consistent, standardised behaviour than humans, and don’t become tired or bored.
    - - Human problem solving ability enables a system to recover from a major failure
      - Automated systems can and often do struggle to respond to situations that were not programmed into their logic
  - - - People encountering situations beyond their abilities
      - Even competent people could face complex situations
      - Confusion, disorientation, distraction
      - Multi-person teams not used in the best way leading to team error
    - - Errors of Commission
        
        erroneous actions (for example a mistake in planning) which cause an incorrect response (e.g. a pilot entering forbidden airspace).
      - Errors of Omission
        
        occur when a person forgets to perform an action, for example landing an aircraft with the undercarriage up.
      - Errors of Substitution
        
        are when one action is substituted in place of the intended one, such as shutting down the wrong engine after a fire indication on the control panel.
      - Errors of Timing
        
        when the right action is carried out but at the wrong time, for example delaying the use of brakes, spoilers or thrust reversers, leading to a runway overrun.
      - Sequencing Errors
        
        occur when the right actions are carried out in the wrong order, such as following a checklist, but not in the correct order
  - - - e.g. inadequate equipment, lack of training, time pressure, staff demotivation
    - - Errors and violations by individuals and teams
    - - e.g. poor strategic decisions, inadequate organizational processes, unhealthy organizational culture
  - - - technical competence
      - attention (or attention deficit)
      - memory
      - perceptions (processing of sensory data)
      - attitude (e.g. a person can be careful to pay attention to detail, or have a tendency to do work carelessly and quickly)
      - judgement and decision making
      - Motivation (Positive or Negative)
      - self-discipline
      - risk taking tendencies (healthy or uncontrolled).
      - Ego (ranging from overconfidence, to positive motivation), loss of face (e.g. a temptation to cover up mistakes?) and peer pressure (which can be pro- or anti-safety)
    - - Upset conditions are unplanned events (often encountered suddenly), outside the normal operating range of a process. These might include:
        
        a process behaving unusually due to external factors (e.g. weather, supply disruption etc.) and/or internal factors (e.g. local heat build-up that leads to process control problems)
        
        a breakdown, or unplanned maintenance in response to this, which cause the process to operate differently to normal, or not as effectively as expected
        
        encountering a hazard that had not been identified previously
        
        any other unanticipated event that distracts managers and/or workers
      - A key response to this is upset training, which can happen in two main ways:
        
        Classroom training
        
        may be very helpful, but prepacked responses can’t anticipate every possible upset, or combination of upsets.
        
        Hands on training
        
        with a plant simulator allows crews to become familiar with upset conditions