Behind Human Error

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Ashgate Publishing, Ltd., 2010 - Technology & Engineering - 271 pages
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This work takes you behind the human error label. Divided into five parts, it summarizes the most significant results, explains the role of normal cognitive system factors in operating safely at the sharp end, tells how hindsight bias always enters into attributions of error, and much more.
 

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User Review  - rhbouchard - LibraryThing

A very interesting perspective. The book makes the case of placing yourself in the shoes of those who made mistakes because hindsight biases any fruitful discussion of problems. Read full review

Contents

AN INTRODUCTION TO THE SECOND STORY
1
THE PROBLEM WITH HUMAN ERROR
3
BASIC PREMISES
19
COMPLEX SYSTEMS FAILURE
35
LINEAR AND LATENT FAILURE MODELS
41
COMPLEXITY CONTROL AND SOCIOLOGICAL MODELS
61
RESILIENCE ENGINEERING
83
OPERATING AT THE SHARP END
97
HOW DESIGN CAN INDUCE ERROR
141
CLUMSY USE OF TECHNOLOGY
143
HOW COMPUTERBASED ARTIFACTS SHAPE COGNITION AND COLLABORATION
155
MODE ERROR IN SUPERVISORY CONTROL
171
HOW PRACTITIONERS ADAPT TO CLUMSY TECHNOLOGY
191
REACTIONS TO FAILURE
197
HINDSIGHT BIAS
199
ERROR AS INFORMATION
215

BRINGING KNOWLEDGE TO BEAR IN CONTEXT
101
MINDSET
113
GOAL CONFLICTS
123
BALANCING ACCOUNTABILITY AND LEARNING
225
SUMMING UP HOW TO GO BEHIND THE LABEL HUMAN ERROR
235
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About the author (2010)

David D. Woods, Ph.D. is Professor at Ohio State University in the Institute for Ergonomics and Past-President of the Human Factors and Ergonomics Society. He was on the board of the National Patient Safety Foundation and served as Associate Director of the Veterans Health Administration's Midwest Center for Inquiry on Patient Safety. He received a Laurels Award from Aviation Week and Space Technology (1995). Together with Erik Hollnagel, he published two books on Joint Cognitive Systems (2006). Sidney Dekker is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia. Previously Professor at Lund University, Sweden, and Director of the Leonardo Da Vinci Center for Complexity and Systems Thinking there, he gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has worked in New Zealand, the Netherlands and England, been Senior Fellow at Nanyang Technological University in Singapore, Visiting Academic in the Department of Epidemiology and Preventive Medicine, Monash University in Melbourne, and Professor of Community Health Science at the Faculty of Medicine, University of Manitoba in Canada. Sidney is author of several best-selling books on system failure, human error, ethics and governance. He has been flying the Boeing 737NG part-time as airline pilot for the past few years. The OSU Foundation in the United States awards a yearly Sidney Dekker Critical Thinking Award. Richard Cook, M.D. is an active physician, Associate Professor in the Department of Anesthesia and Critical Care, and also Director of the Cognitive Technologies Laboratory at the University of Chicago. Dr. Cook was a member of the Board of the National Patient Safety Foundation from its inception until 2007. He counts as a leading expert on medical accidents, complex system failures, and human performance at the sharp end of these systems. Among many other publications, he co-authored A Tale of Two Stories: Contrasting Views of Patient Safety. Leila Johannesen, Ph.D. works as a human factors engineer on the user technology team at the IBM Silicon Valley lab in San Jose, CA. She is a member of the Silicon Valley lab accessibility team focusing on usability sessions with disabled participants and accessibility education for data management product teams. She is author of The Interactions of Alicyn in Cyberland (1994). Nadine Sarter, Ph.D. is Associate Professor in the Department of Industrial and Operations Engineering and the Center for Ergonomics at the University of Michigan. With her pathbreaking research on mode error and automation complexities in modern airliners, she served as technical advisor to the Federal Aviation Administration's Human Factors Team in the 1990's to provide recommendations for the design, operation, and training for advanced 'glass cockpit' aircraft and shared the Aerospace Laurels Award with David Woods.

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