The Field Guide To Human Error Investigations

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The Field Guide to Human Error Investigations

Author : Sidney Dekker
Publisher : Routledge
ISBN 13 : 1351786032
Total Pages : 137 pages
Book Rating : 4.3/5 (517 download)

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Book Synopsis The Field Guide to Human Error Investigations by : Sidney Dekker

Download or read book The Field Guide to Human Error Investigations written by Sidney Dekker and published by Routledge. This book was released on 2017-11-01 with total page 137 pages. Available in PDF, EPUB and Kindle. Book excerpt: This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.

The Field Guide to Understanding Human Error

Author : Sidney Dekker
Publisher : CRC Press
ISBN 13 : 1351889753
Total Pages : 250 pages
Book Rating : 4.3/5 (518 download)

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Book Synopsis The Field Guide to Understanding Human Error by : Sidney Dekker

Download or read book The Field Guide to Understanding Human Error written by Sidney Dekker and published by CRC Press. This book was released on 2017-04-07 with total page 250 pages. Available in PDF, EPUB and Kindle. Book excerpt: When faced with a human error problem, you may be tempted to ask 'Why didn't they watch out better? How could they not have noticed?'. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. 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. This old view of human error is increasingly outdated and will lead you nowhere. The new view, in contrast, understands that a human error problem is actually an organizational problem. Finding a 'human error' by any other name, or by any other human, is only the beginning of your journey, not a convenient conclusion. The new view recognizes that systems are inherent trade-offs between safety and other pressures (for example: production). People need to create safety through practice, at all levels of an organization. Breaking new ground beyond its successful predecessor, The Field Guide to Understanding Human Error guides you through the traps and misconceptions of the old view. It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language. But it also helps you look forward. It suggests how to apply the new view in building your safety department, handling questions about accountability, and constructing meaningful countermeasures. It even helps you in getting your organization to adopt the new view and improve its learning from failure. So if you are faced by a human error problem, abandon the fallacy of a quick fix. Read this book.

Investigating Human Error

Author : Barry Strauch
Publisher : Routledge
ISBN 13 : 1351727028
Total Pages : 261 pages
Book Rating : 4.3/5 (517 download)

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Book Synopsis Investigating Human Error by : Barry Strauch

Download or read book Investigating Human Error written by Barry Strauch and published by Routledge. This book was released on 2018-05-08 with total page 261 pages. Available in PDF, EPUB and Kindle. Book excerpt: This title was first published in 2002: This volume presents a method to investigate the human performance issues associated with an accident or incident, with a detailed discussion of the types of data to collect, and methods of collecting and analyzing data. The book should be of interest to accident/incident investigators, specialists in nuclear, chemical processing, aviation and other critical industries, safety experts, researchers and students in the field of human error, human factors, ergonomics and industrial engineering, and government agencies for regulation, health and safety.

A Human Error Approach to Aviation Accident Analysis

Author : Douglas A. Wiegmann
Publisher : Routledge
ISBN 13 : 1351962353
Total Pages : 174 pages
Book Rating : 4.3/5 (519 download)

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Book Synopsis A Human Error Approach to Aviation Accident Analysis by : Douglas A. Wiegmann

Download or read book A Human Error Approach to Aviation Accident Analysis written by Douglas A. Wiegmann and published by Routledge. This book was released on 2017-12-22 with total page 174 pages. Available in PDF, EPUB and Kindle. Book excerpt: Human error is implicated in nearly all aviation accidents, yet most investigation and prevention programs are not designed around any theoretical framework of human error. Appropriate for all levels of expertise, the book provides the knowledge and tools required to conduct a human error analysis of accidents, regardless of operational setting (i.e. military, commercial, or general aviation). The book contains a complete description of the Human Factors Analysis and Classification System (HFACS), which incorporates James Reason's model of latent and active failures as a foundation. Widely disseminated among military and civilian organizations, HFACS encompasses all aspects of human error, including the conditions of operators and elements of supervisory and organizational failure. It attracts a very broad readership. Specifically, the book serves as the main textbook for a course in aviation accident investigation taught by one of the authors at the University of Illinois. This book will also be used in courses designed for military safety officers and flight surgeons in the U.S. Navy, Army and the Canadian Defense Force, who currently utilize the HFACS system during aviation accident investigations. Additionally, the book has been incorporated into the popular workshop on accident analysis and prevention provided by the authors at several professional conferences world-wide. The book is also targeted for students attending Embry-Riddle Aeronautical University which has satellite campuses throughout the world and offers a course in human factors accident investigation for many of its majors. In addition, the book will be incorporated into courses offered by Transportation Safety International and the Southern California Safety Institute. Finally, this book serves as an excellent reference guide for many safety professionals and investigators already in the field.

Pre-Accident Investigations

Author : Dr Todd Conklin
Publisher : Ashgate Publishing, Ltd.
ISBN 13 : 1409483541
Total Pages : 192 pages
Book Rating : 4.4/5 (94 download)

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Book Synopsis Pre-Accident Investigations by : Dr Todd Conklin

Download or read book Pre-Accident Investigations written by Dr Todd Conklin and published by Ashgate Publishing, Ltd.. This book was released on 2012-10-28 with total page 192 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book is a set of new skills written for the managers that drive safety in their workplace. This is Human Performance theory made simple. If you are starting a new program, revamping an old program, or simply interested in understanding more about safety performance, this guide will be extremely helpful.

Ten Questions About Human Error

Author : Sidney Dekker
Publisher : CRC Press
ISBN 13 : 1410612066
Total Pages : 233 pages
Book Rating : 4.4/5 (16 download)

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Book Synopsis Ten Questions About Human Error by : Sidney Dekker

Download or read book Ten Questions About Human Error written by Sidney Dekker and published by CRC Press. This book was released on 2004-12-27 with total page 233 pages. Available in PDF, EPUB and Kindle. Book excerpt: Ten Questions About Human Error asks the type of questions frequently posed in incident and accident investigations, people's own practice, managerial and organizational settings, policymaking, classrooms, Crew Resource Management Training, and error research. It is one installment in a larger transformation that has begun to identify both deep-rooted constraints and new leverage points of views of human factors and system safety. The ten questions about human error are not just questions about human error as a phenomenon, but also about human factors and system safety as disciplines, and where they stand today. In asking these questions and sketching the answers to them, this book attempts to show where current thinking is limited--where vocabulary, models, ideas, and notions are constraining progress. This volume looks critically at the answers human factors would typically provide and compares/contrasts them with current research insights. Each chapter provides directions for new ideas and models that could perhaps better cope with the complexity of the problems facing human error today. As such, this book can be used as a supplement for a variety of human factors courses.

Behind Human Error

Author : David D. Woods
Publisher : CRC Press
ISBN 13 : 1317175530
Total Pages : 292 pages
Book Rating : 4.3/5 (171 download)

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Book Synopsis Behind Human Error by : David D. Woods

Download or read book Behind Human Error written by David D. Woods and published by CRC Press. This book was released on 2017-09-18 with total page 292 pages. Available in PDF, EPUB and Kindle. Book excerpt: Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reveals about how a system functions or malfunctions. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how systems thinking has radically changed our understanding of how accidents occur. Part 3 explains the role of cognitive system factors - bringing knowledge to bear, changing mindset as situations and priorities change, and managing goal conflicts - in operating safely at the sharp end of systems. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in many different fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, so that what we label human error actually is the result of a social and psychological judgment process by stakeholders in the system in question to focus on only a facet of a set of interacting contributors. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.

Second Victim

Author : Sidney Dekker
Publisher : CRC Press
ISBN 13 : 146658341X
Total Pages : 131 pages
Book Rating : 4.4/5 (665 download)

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Book Synopsis Second Victim by : Sidney Dekker

Download or read book Second Victim written by Sidney Dekker and published by CRC Press. This book was released on 2013-03-26 with total page 131 pages. Available in PDF, EPUB and Kindle. Book excerpt: How do people cope with having "caused" a terrible accident? How do they cope when they survive and have to live with the consequences ever after? We tend to blame and forget professionals who cause incidents and accidents, but they are victims too. They are second victims whose experiences of an incident or adverse event can be as traumatic as that of the first victims’. Yet information on second victimhood and its relationship to safety, about what is known and what organizations might need to do, is difficult to find. Thoroughly exploring an emerging topic with great relevance to safety culture, Second Victim: Error, Guilt, Trauma, and Resilience examines the lived experience of second victims. It goes through what we know about trauma, guilt, forgiveness, and injustice and how these might be felt by the second victim. The author discusses how to conduct investigations of incidents that do not alienate second victims or make them feel even worse. It explores the importance support and resilience and where the responsibilities for creating it may lie. Drawing on his unique background as psychologist, airline pilot, and safety specialist, and his own experiences with helping second victims from a variety of backgrounds, Sidney Dekker has written a powerful, moving account of the experience of the second victim. It forms compelling reading for practitioners, risk managers, human resources managers, safety experts, mental health workers, regulators, the judiciary, and many other professionals. Dekker provides a strong theoretical background to promote understanding of the situation of the second victim and solid practical advice about how to deal with trauma that continues after an event leading to preventable harm or even avoidable death of a patient, consumer, or colleague. Listen to Sidney Dekker speak about his book

Drift into Failure

Author : Sidney Dekker
Publisher : CRC Press
ISBN 13 : 1351942913
Total Pages : 332 pages
Book Rating : 4.3/5 (519 download)

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Book Synopsis Drift into Failure by : Sidney Dekker

Download or read book Drift into Failure written by Sidney Dekker and published by CRC Press. This book was released on 2016-12-05 with total page 332 pages. Available in PDF, EPUB and Kindle. Book excerpt: What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner’s tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and normality that gives rise to such large events. We hunt for broken parts, fixable properties, people we can hold accountable. Our analyses of complex system breakdowns remain depressingly linear, depressingly componential - imprisoned in the space of ideas once defined by Newton and Descartes. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. Our technologies have gotten ahead of our theories. We are able to build things - deep-sea oil rigs, jackscrews, collateralized debt obligations - whose properties we understand in isolation. But in competitive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness complexity and find new ways of managing drift.

Safety and Ethics in Healthcare: A Guide to Getting it Right

Author : Professor Alan Merry
Publisher : Ashgate Publishing, Ltd.
ISBN 13 : 1409485005
Total Pages : 375 pages
Book Rating : 4.4/5 (94 download)

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Book Synopsis Safety and Ethics in Healthcare: A Guide to Getting it Right by : Professor Alan Merry

Download or read book Safety and Ethics in Healthcare: A Guide to Getting it Right written by Professor Alan Merry and published by Ashgate Publishing, Ltd.. This book was released on 2012-10-01 with total page 375 pages. Available in PDF, EPUB and Kindle. Book excerpt: A single coherent source of information on the various interlinking domains of patient safety, litigation and ethical behaviour, based on accounts of real-life situations and intended for all healthcare students, specialists and administrators.

The Source Field Investigations

Author : David Wilcock
Publisher : Penguin
ISBN 13 : 0452297974
Total Pages : 562 pages
Book Rating : 4.4/5 (522 download)

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Book Synopsis The Source Field Investigations by : David Wilcock

Download or read book The Source Field Investigations written by David Wilcock and published by Penguin. This book was released on 2012-07-31 with total page 562 pages. Available in PDF, EPUB and Kindle. Book excerpt: Prepare yourself for a revealing tour through the most incredible scientific mysteries of the world with your guide David Wilcock, the New York Times bestselling author of Awakening in the Dream. More than two million people have seen David Wilcock’s incredible tour of the 2012 prophecies in his Internet documentary, The 2012 Enigma. Now, he expands his vision with a cutting-edge investigation into alternative sciences with deep insights into what is coming in our immediate future. A stunning synthesis of hidden science and lost prophecies, The Source Field Investigations exposes DNA transformation, wormholes, ancient conspiracies, the Maya calendar, and a new model of galactic energy fields triggering mental, biological, and spiritual evolution. Unlike the apocalyptic viewpoints depicted in big-budget disaster films, Wilcock believes that 2012 will be a watermark for widespread acceptance of a greater reality—and here, he lays out the blueprints for such a Golden Age.

Safety Differently

Author : Sidney Dekker
Publisher : CRC Press
ISBN 13 : 1482242001
Total Pages : 304 pages
Book Rating : 4.4/5 (822 download)

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Book Synopsis Safety Differently by : Sidney Dekker

Download or read book Safety Differently written by Sidney Dekker and published by CRC Press. This book was released on 2014-06-23 with total page 304 pages. Available in PDF, EPUB and Kindle. Book excerpt: The second edition of a bestseller, Safety Differently: Human Factors for a New Era is a complete update of Ten Questions About Human Error: A New View of Human Factors and System Safety. Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking. Automation and new technologies have resu

The Human Contribution

Author : J. T. Reason
Publisher : Ashgate Publishing, Ltd.
ISBN 13 : 9780754674009
Total Pages : 320 pages
Book Rating : 4.6/5 (74 download)

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Book Synopsis The Human Contribution by : J. T. Reason

Download or read book The Human Contribution written by J. T. Reason and published by Ashgate Publishing, Ltd.. This book was released on 2008 with total page 320 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.

Diagnosis

Author : Pat Croskerry
Publisher : CRC Press
ISBN 13 : 135165019X
Total Pages : 370 pages
Book Rating : 4.3/5 (516 download)

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Book Synopsis Diagnosis by : Pat Croskerry

Download or read book Diagnosis written by Pat Croskerry and published by CRC Press. This book was released on 2017-09-19 with total page 370 pages. Available in PDF, EPUB and Kindle. Book excerpt: Despite diagnosis being the key feature of a physician's clinical performance, this is the first book that deals specifically with the topic. In recent years, however, considerable interest has been shown in this area and significant developments have occurred in two main areas: a) an awareness and increasing understanding of the critical role of clinical decision making in the process of diagnosis, and of the multiple factors that impact it, and b) a similar appreciation of the role of the healthcare system in supporting clinicians in their efforts to make accurate diagnoses. Although medicine has seen major gains in knowledge and technology over the last few decades, there is a consensus that the diagnostic failure rate remains in the order of 10-15%. This book provides an overview of the major issues in this area, in particular focusing on where the diagnostic process fails, and where improvements might be made.

Just Culture

Author : Sidney Dekker
Publisher : Ashgate Publishing, Ltd.
ISBN 13 : 1409440605
Total Pages : 201 pages
Book Rating : 4.4/5 (94 download)

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Book Synopsis Just Culture by : Sidney Dekker

Download or read book Just Culture written by Sidney Dekker and published by Ashgate Publishing, Ltd.. This book was released on 2012 with total page 201 pages. Available in PDF, EPUB and Kindle. Book excerpt: While many organizations see the value of creating a just culture they struggle when it comes to developing it. In this Second Edition, Dekker expands his views, additionally tackling the key issue of how justice is created inside organizations. Dekker also introduces new material on ethics and on caring for the' second victim' (the professional at the centre of the incident). Consequently, we have a natural evolution of the author's ideas.

Just Culture

Author : Sidney Dekker
Publisher : CRC Press
ISBN 13 : 1317109899
Total Pages : 250 pages
Book Rating : 4.3/5 (171 download)

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Book Synopsis Just Culture by : Sidney Dekker

Download or read book Just Culture written by Sidney Dekker and published by CRC Press. This book was released on 2018-09-07 with total page 250 pages. Available in PDF, EPUB and Kindle. Book excerpt: A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimize the negative impact, and maximize learning? This third edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the criminalization of human error. Some suspect a just culture means letting people off the hook. Yet they believe they need to remain able to hold people accountable for undesirable performance. In this new edition, Dekker asks you to look at 'accountability' in different ways. One is by asking which rule was broken, who did it, whether that behavior crossed some line, and what the appropriate consequences should be. In this retributive sense, an 'account' is something you get people to pay, or settle. But who will draw that line? And is the process fair? Another way to approach accountability after an incident is to ask who was hurt. To ask what their needs are. And to explore whose obligation it is to meet those needs. People involved in causing the incident may well want to participate in meeting those needs. In this restorative sense, an 'account' is something you get people to tell, and others to listen to. Learn to look at accountability in different ways and your impact on restoring trust, learning and a sense of humanity in your organization could be enormous.

Organizational Accidents Revisited

Author : Professor James Reason
Publisher : Ashgate Publishing, Ltd.
ISBN 13 : 1472447670
Total Pages : 136 pages
Book Rating : 4.4/5 (724 download)

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Book Synopsis Organizational Accidents Revisited by : Professor James Reason

Download or read book Organizational Accidents Revisited written by Professor James Reason and published by Ashgate Publishing, Ltd.. This book was released on 2016-01-28 with total page 136 pages. Available in PDF, EPUB and Kindle. Book excerpt: Managing the Risks of Organizational Accidents introduced the notion of an ‘organizational accident’. These are rare but often calamitous events that occur in complex technological systems operating in hazardous circumstances. They stand in sharp contrast to ‘individual accidents’ whose damaging consequences are limited to relatively few people or assets. Although they share some common causal factors, they mostly have quite different causal pathways. The frequency of individual accidents - usually lost-time injuries - does not predict the likelihood of an organizational accident. The book also elaborated upon the widely-cited Swiss Cheese Model. Organizational Accidents Revisited extends and develops these ideas using a standardised causal analysis of some 10 organizational accidents that have occurred in a variety of domains in the nearly 20 years that have passed since the original was published. These analyses provide the ‘raw data’ for the process of drilling down into the underlying causal pathways. Many contributing latent conditions recur in a variety of domains. A number of these - organizational issues, design, procedures and so on - are examined in close detail in order to identify likely problems before they combine to penetrate the defences-in-depth. Where the 1997 book focused largely upon the systemic factors underlying organisational accidents, this complementary follow-up goes beyond this to examine what can be done to improve the ‘error wisdom’ and risk awareness of those on the spot; they are often the last line of defence and so have the power to halt the accident trajectory before it can cause damage. The book concludes by advocating that system safety should require the integration of systemic factors (collective mindfulness) with individual mental skills (personal mindfulness).