The Field Guide to Understanding 'Human Error'
Ashgate Publishing, Ltd., Dec 28, 2014 - Technology & Engineering - 248 pages
When faced with a ‘human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it. Building on its successful predecessors, the third edition of The Field Guide to Understanding ‘Human Error’ will help you understand a new way of dealing with a perceived 'human error' problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a ‘human error’ problem, abandon the fallacy of a quick fix. Read this book.
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Two Views of human error
Containing your reactions to Failure
doing a human error investigation
explaining the Patterns of Breakdown
understanding your accident model
Creating an effective safety department
Building a safety Culture
abandoning the Fallacy of a Quick Fix
Speaking for the Dead
Other editions - View all
accident accountability actions actually air traffic control aircraft airline airport airspeed aldershot approach ashgate assessments automation aviation Bad apples cause checklist cockpit cognitive complacency complex construction context conversation analysis crash crew crew resource management cues decision dekker Drift into failure engineering example explain Field Guide Figure flight flight management system focus happen hindsight hindsight bias hollnagel human factors incidents injuries inside interaction investigation involved learning look loss of situation managed upward means mishap monitoring normal Old View operators organization organization’s organizational outcome Paul Fitts people’s pilots practitioners pressures problem procedures question resilience responsibility restorative justice risk runway safety culture safety department safety management second victims sense sequence of events sharp end situation awareness speed swissair 111 tasks thin edge things timeline ultra-safe understand human error unsafe workers zero vision