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Aircrew Coordination Training
ACT-01
E.
Identifying links in an error chain
1.
Mishaps seldom are caused by one factor, but rather by a chain
of events that cumulate in a mishap/incident
2.
By breaking one link, mishap/incident may be avoided
3.
Easy to find AFTER mishap, often hard to detect as they occur
4.
Eleven clues to help identify:
a.
Presence does not mean mishap/incident will occur
b.
Rather, presence indicates risk in operating aircraft is
rising, and crew must maintain proper control through use
of all resources
5.
Error chain clues:
a.
No one flying the plane or monitoring the current state of
progress
b.
No one looking out of the window
c.
Ambiguity exists anytime two or more independent sources
of information do not agree--gauges, people, senses,
throttle position that does not agree with power indications,
and so on
d.
Distraction/preoccupation--the focusing of attention on any
one item to the exclusion of all others
e.
Confused or empty feeling--a sense of bafflement,
uncertainty
(1) Often evidenced by physiological systems
(2) “When the little people start talking to you”
f.
Use of any undocumented procedure--does the crew using
procedures not prescribed in NATOPS/SOPs have a
thorough understanding of the problem
g.
Violating limitations/regulations
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