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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.
Human error is so often cited as a cause of accidents. There is perception of a 'human error problem'. Solutions are thought to lie in changing the people or their role. The label 'human error', however, is prejudicial and hides more than it reveals about how a system malfunctions. This book takes you behind the label. It explains how human error results from social and psychological judgments by the system's stakeholders that focus only on one facet of a set of interacting contributors.
Human error is so often cited as a cause of accidents. There is perception of a 'human error problem'. Solutions are thought to lie in changing the people or their role. The label 'human error', however, is prejudicial and hides more than it reveals about how a system malfunctions.This book takes you behind the label. It explains how human error results from social and psychological judgments by the system's stakeholders that focus only on one facet of a set of interacting contributors.
This 1991 book is a major theoretical integration of several previously isolated literatures looking at human error in major accidents.
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.
Accidents happen because of the reduction in adaptable capabilities or because inadaptability takes over. Inadaptability is the failure to adapt according to changed circumstances, settings or time. The occurrence of human errors in manual assembly lines can be affected by factors, such as workplace condition, work environment, equipment and demographics factors. Another topic explored in this book is forensic science which is concerned with the application of scientific knowledge to legal problem resolution. It is a vital tool in any legal proceeding, because it helps the judge and the jury to understand scientific truth. Also, human error in medicine is a major threat to patient safety. Therefore, it is vital to reveal factors that cause performance deficits in medical work environments. On the basis of the human error sources identified, human factors training programs can be designed as one possible approach to preventing accidents and increasing safety. Human error has been cited as a common cause in disasters and accidents in diverse high-risk industries and in healthcare. This book focuses on organizational, social and individual causes for the development of conditions behind human errors.
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.
"[W]onderful, enlightened, and convincing beyond any reasonable expectations of what a science fiction novel should be." —Greg Bear Compugen has become a giant player in the tech field overnight by making genetically altered viruses into "biochips" that are replacing silicon chips as the brains of computers. Toby Bridgeman and Adrian Storey are an odd-couple of scientists—Toby, the programmer, and Adrian, the sloppy genius and genetic artist, have formed an enduring friendship and produced Epicell, a biochip so powerful that it will make all others on the market obsolete and save Compugen from financial disaster—if it can be rushed out fast enough. But Epicell, elemental living virus, is so awesome in its capabilities that tests have not yet established any limits to its multiplication or its computing sophistication. Adrian wants more testing—he believes that Epicell is potentially dangerous. Instead, it is rushed to market to save the failing company. Then those in contact with Epicell begin to come down with bad colds—the virus has spread outside computers, living and growing in the human body. Adrian, and perhaps the human race, are doomed unless Toby can reprogram the Epicell inside Adrian—and inside himself.
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.
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.