Drift Into Failure

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Drift into Failure

Sidney Dekker
Drift into Failure Book PDF

Author : Sidney Dekker
Publisher : CRC Press
Page : 332 pages
File Size : 46,8 Mb
Release : 2016-12-05
Category : Technology & Engineering
ISBN : 9781351942911

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Drift into Failure by Sidney Dekker Pdf

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.

Drift into Failure

Professor Sidney Dekker
Drift into Failure Book PDF

Author : Professor Sidney Dekker
Publisher : Ashgate Publishing, Ltd.
Page : 277 pages
File Size : 44,6 Mb
Release : 2012-10-01
Category : Psychology
ISBN : 9781409486558

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Drift into Failure by Professor Sidney Dekker Pdf

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 Differently

Sidney Dekker
Safety Differently Book PDF

Author : Sidney Dekker
Publisher : CRC Press
Page : 304 pages
File Size : 48,9 Mb
Release : 2014-06-23
Category : Technology & Engineering
ISBN : 9781482242003

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Safety Differently by Sidney Dekker Pdf

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 Field Guide to Human Error Investigations

Sidney Dekker
The Field Guide to Human Error Investigations Book PDF

Author : Sidney Dekker
Publisher : Routledge
Page : 137 pages
File Size : 48,8 Mb
Release : 2017-11-01
Category : Social Science
ISBN : 9781351786034

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The Field Guide to Human Error Investigations by Sidney Dekker Pdf

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.

Behind Human Error

David D. Woods,Sidney Dekker,Richard Cook,Leila Johannesen,Nadine Sarter
Behind Human Error Book PDF

Author : David D. Woods,Sidney Dekker,Richard Cook,Leila Johannesen,Nadine Sarter
Publisher : CRC Press
Page : 292 pages
File Size : 52,6 Mb
Release : 2017-09-18
Category : Technology & Engineering
ISBN : 9781317175537

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Behind Human Error by David D. Woods,Sidney Dekker,Richard Cook,Leila Johannesen,Nadine Sarter Pdf

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.

Foundations of Safety Science

Sidney Dekker
Foundations of Safety Science Book PDF

Author : Sidney Dekker
Publisher : Routledge
Page : 530 pages
File Size : 52,6 Mb
Release : 2019-04-09
Category : Technology & Engineering
ISBN : 9781351059770

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Foundations of Safety Science by Sidney Dekker Pdf

How are today’s ‘hearts and minds’ programs linked to a late-19th century definition of human factors as people’s moral and mental deficits? What do Heinrich’s ‘unsafe acts’ from the 1930’s have in common with the Swiss cheese model of the early 1990’s? Why was the reinvention of human factors in the 1940’s such an important event in the development of safety thinking? What makes many of our current systems so complex and impervious to Tayloristic safety interventions? ‘Foundations of Safety Science’ covers the origins of major schools of safety thinking, and traces the heritage and interlinkages of the ideas that make up safety science today. Features Offers a comprehensive overview of the theoretical foundations of safety science Provides balanced treatment of approaches since the early 20th century, showing interlinkages and cross-connections Includes an overview and key points at the beginning of each chapter and study questions at the end to support teaching use Uses an accessible style, using technical language where necessary Concentrates on the philosophical and historical traditions and assumptions that underlie all safety approaches

Just Culture

Sidney Dekker
Just Culture Book PDF

Author : Sidney Dekker
Publisher : Ashgate Publishing, Ltd.
Page : 201 pages
File Size : 55,6 Mb
Release : 2012
Category : Technology & Engineering
ISBN : 9781409440604

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Just Culture by Sidney Dekker Pdf

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.

Drift

Rachel Maddow
Drift Book PDF

Author : Rachel Maddow
Publisher : Crown
Page : 285 pages
File Size : 55,7 Mb
Release : 2012-03-27
Category : Political Science
ISBN : 9780307461001

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Drift by Rachel Maddow Pdf

The #1 New York Times bestseller that charts America’s dangerous drift into a state of perpetual war. Written with bracing wit and intelligence, Rachel Maddow's Drift argues that we've drifted away from America's original ideals and become a nation weirdly at peace with perpetual war. To understand how we've arrived at such a dangerous place, Maddow takes us from the Vietnam War to today's war in Afghanistan, along the way exploring Reagan's radical presidency, the disturbing rise of executive authority, the gradual outsourcing of our war-making capabilities to private companies, the plummeting percentage of American families whose children fight our constant wars for us, and even the changing fortunes of G.I. Joe. Ultimately, she shows us just how much we stand to lose by allowing the scope of American military power to overpower our political discourse. Sensible yet provocative, dead serious yet seri­ously funny, Drift reinvigorates a "loud and jangly" political debate about our vast and confounding national security state.

The Defence of Duffer's Drift

E. D. Swinton
The Defence of Duffer s Drift Book PDF

Author : E. D. Swinton
Publisher : Good Press
Page : 57 pages
File Size : 46,9 Mb
Release : 2019-11-19
Category : Science
ISBN : EAN:4057664126924

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The Defence of Duffer's Drift by E. D. Swinton Pdf

The Defence of Duffer's Drift is a concise story by Ernest Dunlop Swinton. Lieutenant Backsight Forethought and his rule of fifty soldiers are given the task to uphold Duffer's Drift, a natural crossing to a tactically important river.

Managing the Risks of Organizational Accidents

James Reason
Managing the Risks of Organizational Accidents Book PDF

Author : James Reason
Publisher : Routledge
Page : 272 pages
File Size : 46,7 Mb
Release : 2016-01-29
Category : Technology & Engineering
ISBN : 9781134855353

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Managing the Risks of Organizational Accidents by James Reason Pdf

Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.

Second Victim

Sidney Dekker
Second Victim Book PDF

Author : Sidney Dekker
Publisher : CRC Press
Page : 131 pages
File Size : 50,9 Mb
Release : 2013-03-26
Category : Medical
ISBN : 9781466583412

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Second Victim by Sidney Dekker Pdf

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

Safety-I and Safety-II

Erik Hollnagel
Safety I and Safety II Book PDF

Author : Erik Hollnagel
Publisher : CRC Press
Page : 167 pages
File Size : 49,7 Mb
Release : 2018-04-17
Category : Technology & Engineering
ISBN : 9781317059790

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Safety-I and Safety-II by Erik Hollnagel Pdf

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

Outwitting the Devil

Napoleon Hill
Outwitting the Devil Book PDF

Author : Napoleon Hill
Publisher : Sharon Lechter
Page : 30 pages
File Size : 55,7 Mb
Release : 2011
Category : Self-Help
ISBN : 8210379456XXX

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Outwitting the Devil by Napoleon Hill Pdf

Originally written in 1938 but never published due to its controversial nature, an insightful guide reveals the seven principles of good that will allow anyone to triumph over the obstacles that must be faced in reaching personal goals.

Just Culture

Sidney Dekker
Just Culture Book PDF

Author : Sidney Dekker
Publisher : CRC Press
Page : 250 pages
File Size : 44,7 Mb
Release : 2018-09-07
Category : Technology & Engineering
ISBN : 9781317109891

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Just Culture by Sidney Dekker Pdf

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.

The Safety Anarchist

Sidney Dekker
The Safety Anarchist Book PDF

Author : Sidney Dekker
Publisher : Routledge
Page : 220 pages
File Size : 51,6 Mb
Release : 2017-10-19
Category : Technology & Engineering
ISBN : 9781351403634

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The Safety Anarchist by Sidney Dekker Pdf

Work has never been as safe as it seems today. Safety has also never been as bureaucratized as it is today. Over the past two decades, the number of safety rules and statutes has exploded, and organizations themselves are creating ever more internal compliance requirements. At the same time, progress on safety has slowed to a crawl. Many incident- and injury rates have flatlined. Worse, excellent safety performance on low-consequence events tends to increase the risk of fatalities and disasters. Bureaucracy and compliance now seem less about managing the safety of the workers we are responsible for, and more about managing the liability of the people they work for. We make workers do a lot that does nothing to improve their success locally. Paradoxically, such tightening of safety bureaucracy robs us of exactly the source of human insight, creativity and resilience that can tell us how success is actually created, and where the next accident may well happen. It is time for Safety Anarchists: people who trust people more than process, who rely on horizontally coordinating experiences and innovations, who push back against petty rules and coercive compliance, and who help recover the dignity and expertise of human work.