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Accident investigation and risk assessment have for decades focused on the human factor, particularly ‘human error’. This bias towards performance failures leads to a neglect of normal performance. It assumes that failures and successes have different origins so there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The alternative is to understand why things go right and to amplify that. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions. It proposes that this efficiency-thoroughness trade-off (ETTO) is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the same processes that produce successes.
Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. This bias towards performance failures leads to a neglect of normal performance. It assumes that failures and successes have different origins so there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The alternative is to understand why things go right and to amplify that.The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions. It proposes that this efficiency-thoroughness trade-off (ETTO) is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the same processes that produce successes.
For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real world, rather than a malfunction. Human performance must continually adjust to current conditions and, because resources and time are finite, such adjustments are always approximate. Featuring contributions from leading international figures in human factors and safety, Resilience Engineering provides thought-provoking insights into system safety as an aggregate of its various components - subsystems, software, organizations, human behaviours - and the way in which they interact.
Accident investigation and risk assessment have for decades focused on the human factor, particularly 'human error'. Countless books and papers have been written about how to identify, classify, eliminate, prevent and compensate for it. This bias towards the study of performance failures, leads to a neglect of normal or 'error-free' performance and the assumption that as failures and successes have different origins there is little to be gained from studying them together. Erik Hollnagel believes this assumption is false and that safety cannot be attained only by eliminating risks and failures. The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions - to what has happened, to what happens, and to what may happen. It proposes that this efficiency-thoroughness trade-off (ETTO) - usually sacrificing thoroughness for efficiency - is normal. While in some cases the adjustments may lead to adverse outcomes, these are due to the very same processes that produce successes, rather than to errors and malfunctions. The ETTO Principle removes the need for specialised theories and models of failure and 'human error' and offers a viable basis for effective and just approaches to both reactive and proactive safety management.
Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ’avoiding that something goes wrong’ to ’ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret
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
Based on a wide range of consultations with maritime organisations, the guide was produced by organisational psychologists gs partnership ltd, for consortium partners UK Maritime and Coastguard Agency, BP Shipping, Teekay Marine Services, and the Standard P&I Club. Aimed at everyone in the shipping industry, the Guide explains the fundamental aspects of human behaviour, which together constitute what the commercial maritime sector calls 'the human element'. It makes clear that the human element is neither peripheral nor optional in the pursuit of a profitable and safe shipping industry. The Guide clearly shows that managing the human element must take place simultaneously at all levels of the industry. Analysis of continuing shipping disasters has increasingly implicated the human element. The loss of life, the impact on company profits and credibility, and the vast environmental damage that can result from the loss of even a single vessel remain clear. The Guide offers insight, explanation and advice to help manage the human element more effectively, more safely and more profitably.
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.
A Fresh and Important New Way to Understand Why We Buy Why did the RAZR ultimately ruin Motorola? Why does Wal-Mart dominate rural and suburban areas but falter in large cities? Why did Starbucks stumble just when it seemed unstoppable? The answer lies in the ever-present tension between fidelity (the quality of a consumer’s experience) and convenience (the ease of getting and paying for a product). In Trade-Off, Kevin Maney shows how these conflicting forces determine the success, or failure, of new products and services in the marketplace. He shows that almost every decision we make as consumers involves a trade-off between fidelity and convenience–between the products we love and the products we need. Rock stars sell out concerts because the experience is high in fidelity-–it can’t be replicated in any other way, and because of that, we are willing to suffer inconvenience for the experience. In contrast, a downloaded MP3 of a song is low in fidelity, but consumers buy music online because it’s superconvenient. Products that are at one extreme or the other–those that are high in fidelity or high in convenience–-tend to be successful. The things that fall into the middle-–products or services that have moderate fidelity and convenience-–fail to win an enthusiastic audience. Using examples from Amazon and Disney to People Express and the invention of the ATM, Maney demonstrates that the most successful companies skew their offerings to either one extreme or the other-–fidelity or convenience-–in shaping products and building brands.
Accidents are preventable, but only if they are correctly described and understood. Since the mid-1980s accidents have come to be seen as the consequence of complex interactions rather than simple threads of causes and effects. Yet progress in accident models has not been matched by advances in methods. The author's work in several fields (aviation, power production, traffic safety, healthcare) made it clear that there is a practical need for constructive methods and this book presents the experiences and the state-of-the-art. The focus of the book is on accident prevention rather than accident analysis and unlike other books, has a proactive rather than reactive approach. The emphasis on design rather than analysis is a trend also found in other fields. Features of the book include: -A classification of barrier functions and barrier systems that will enable the reader to appreciate the diversity of barriers and to make informed decisions for system changes. -A perspective on how the understanding of accidents (the accident model) largely determines how the analysis is done and what can be achieved. The book critically assesses three types of accident models (sequential, epidemiological, systemic) and compares their strengths and weaknesses. -A specific accident model that captures the full complexity of systemic accidents. One consequence is that accidents can be prevented through a combination of performance monitoring and barrier functions, rather than through the elimination or encapsulation of causes. -A clearly described methodology for barrier analysis and accident prevention. Written in an accessible style, Barriers and Accident Prevention is designed to provide a stimulating and practical guide for industry professionals familiar with the general ideas of accidents and human error. The book is directed at those involved with accident analysis and system safety, such as managers of safety departments, risk and safety consultants, human factors professionals, and accident investigators. It is applicable to all major application areas such as aviation, ground transportation, maritime, process industries, healthcare and hospitals, communication systems, and service providers.