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原文传递 Error Types and Related Error Detection Processes in the Aviation Domain

题名：	Error Types and Related Error Detection Processes in the Aviation Domain
作者：	Alexander, Heather M.;
关键词：	AVIATION ACCIDENTS, AVIATION SAFETY, PREVENTION, DETECTION, COCKPITS, PERFORMANCE(HUMAN), PILOTS, ERRORS, KNOWLEDGE BASED SYSTEMS, CORRECTIONS.
摘要：	Human error has been identified as a contributing factor in 75-80%of all aviation accidents. To date, most efforts to improve flight safety have focused on error prevention. A different approach that has received less attention is to avoid the negative consequences of erroneous actions and assessments by supporting their timely detection. In this study, aviation incidents were analyzed in terms of the type of error involved (errors of omission and commission; slips, lapses, and mistakes), the performance level at which the error occurred (skill-, rule-, or knowledge-based performance), and the relation between error types and error detection processes that prevented these incidents from turning into accidents. The majority of reported errors were lapses, i.e., failures to perform a required action, and mistakes, i.e., errors in the formation of an intention. Relatively few slips, i.e., inappropriate executions of intended actions, were reported. Slips appear to be detected and corrected by the pilot before they result in an unsafe situation that is worth reporting. Lapses and mistakes, on the other hand, are more difficult for the pilot committing the error to detect and, in most cases, required intervention by air traffic control. A large percentage of lapses resulted from inattention, either due to some distraction in the cockpit or due to multiple competing demands. Mistakes, on the other hand, frequently occurred as a consequence of some misunderstanding between pilots and air traffic controllers concerning clearances and intentions. Most lapses were detected incidentally based on routine checks of aircraft settings and performance, whereas errors of commission, which include both mistakes and slips, were detected equally often based on monitoring for the immediate outcome of an action and by routine checks. These findings indicate the need for more effective support of error detection, particularly in the case of lapses and mistakes.
总页数：	75
报告类型：	科技报告