CAP 737 Crew Resource Management (CRM) Training 机组资源管理培训(57)

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j)  Turboprop Engine Malfunction Recognition and Response. Training video and notes. In preparation - may be ready late 2002 or early 2003. For further information, write to FAA Engine and Propellor Directorate, ANE-110, 12 New England Executive Park, Burlington, MA 01803, USA
k) Approach and Landing Accident Reduction (ALAR) Toolkit. 2000/2001. Flight Safety Foundation. Free to FSF members. www.flightsafety.org/pdf/alar_flyer.pdf
l)  Amalberti, R. The pilot's intellectual abilities and limitations. Chapter 3 of "Briefings: A Human Factors Course for Pilots - Reference Manual". Dédale. 1994 (and reissued in 2000). Publishers, Dédale France.
Appendix 5  Human Error, Reliability and Error Management

 

1 Introduction
The science of Human Factors accepts the fact that human error is inevitable - what is important is to ensure that human error does not result in adverse events such as air accidents. This can be addressed in two ways: reducing errors in the first place, and controlling errors such that they, or their immediate effects, are detected early enough to allow remedial action. CRM addresses both types of mitigating strategies, but concentrates particularly on error detection, especially in the multi-crew situation.
Human reliability is the science which looks at the vulnerability of human beings to error (or less than perfect performance) under different circumstance. One could argue that it is more of an art than a science, since it is very difficult to predict, in quantifiable terms, human reliability in different situations, and from individual to individual. However, there are certain conditions under which humans are more likely to make errors (e.g. during circadian lows, when stressed, when overloaded, etc.), but these will be covered in other Appendices rather than under "human reliability" as such. If readers wish to find further information on the science of human reliability, a few references are included at the end of this Appendix.
The following text, which draws heavily from Professor James Reason's book "Human Error", explains some of the basic theory of human error.

2 Basic Theory
2.1 Introduction to human error
It has long been acknowledged that human performance is at times imperfect. Nearly two thousand years ago, the Roman philosopher Cicero cautioned “It is the nature of man to err”. It is an unequivocal fact that whenever men and women are involved in an activity, human error will occur at some point.
In his book “Human Error”, Professor James Reason defines error as follows:
“Error will be taken as a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency”.

2.2 Error Models and Theories
To appreciate the types of error that it is possible to make, researchers have looked at human error in a number of ways and proposed various models and theories. These attempt to capture the nature of the error and its characteristics. To illustrate this, the following models and theories will be briefly highlighted:
　
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