Investigation Of Human Factors In Accidents And Incidents
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Investigation of Human Factors in Accidents and Incidents by Anonim Pdf
Human Factors (HF) are involved in most aviation occurrences. To advance aviation safety, we must improve our ability to identify the involvement of HF in accidents and incidents. This report: provides investigators and investigation authorities, civil aviation regulatory authorities, corp. mgmt., and other aviation personnel with info. on the need for and purpose of the investigation of HF; outlines a methodology for investigating HF in aircraft accidents and incidents; and describes how the information gathered should be reported. The focus is on the events which led up to the occurrence and not on post-accident events, such as search and rescue and survivability.
Investigating Human Error: Incidents, Accidents and Complex Systems by Barry Strauch Pdf
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 by Douglas A. Wiegmann,Scott A. Shappell Pdf
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.
Human Factors Methods and Accident Analysis by Paul M. Salmon,Neville A. Stanton,Michael Lenné,Daniel P. Jenkins,Laura Rafferty,Guy H. Walker Pdf
This book provides an overview of, and practical guidance on, the range of human factors (HF) methods that can be used for the purposes of accident analysis and investigation in complex sociotechnical systems. Human Factors Methods and Accident Analysis begins with an overview of different accident causation models and an introduction to the concepts of accident analysis and investigation. It then presents a discussion focussing on the importance of, and difficulties associated with, collecting appropriate data for accident analysis purposes. Following this, a range of HF-based accident analysis methods are described, as well as step-by-step guidance on how to apply them. To demonstrate how the different methods are applied, and what the outputs are, the book presents a series of case study applications across a range of safety critical domains. It concludes with a chapter focussing on the data challenges faced when collecting, coding and analysing accident data, along with future directions in the area. Human Factors Methods and Accident Analysis is the first book to offer a practical guide for investigators, practitioners and researchers wishing to apply accident analysis methods. It is also unique in presenting a series of novel applications of accident analysis methods, including HF methods not previously used for these purposes (e.g. EAST, critical path analysis), as well as applications of methods in new domains.
Human Factors Methods and Accident Analysis by Paul M. Salmon,Neville A. Stanton,Michael Lenné,Daniel P. Jenkins,Laura Rafferty,Guy H. Walker Pdf
This book provides an overview of, and practical guidance on, the range of human factors (HF) methods that can be used for the purposes of accident analysis and investigation in complex sociotechnical systems. Human Factors Methods and Accident Analysis begins with an overview of different accident causation models and an introduction to the concepts of accident analysis and investigation. It then presents a discussion focussing on the importance of, and difficulties associated with, collecting appropriate data for accident analysis purposes. Following this, a range of HF-based accident analysis methods are described, as well as step-by-step guidance on how to apply them. To demonstrate how the different methods are applied, and what the outputs are, the book presents a series of case study applications across a range of safety critical domains. It concludes with a chapter focussing on the data challenges faced when collecting, coding and analysing accident data, along with future directions in the area. Human Factors Methods and Accident Analysis is the first book to offer a practical guide for investigators, practitioners and researchers wishing to apply accident analysis methods. It is also unique in presenting a series of novel applications of accident analysis methods, including HF methods not previously used for these purposes (e.g. EAST, critical path analysis), as well as applications of methods in new domains.
In this book the author applies contemporary error theory to the needs of investigators and of anyone attempting to understand why someone made a critical error, how that error led to an incident or accident, and how to prevent such errors in the future. Students and investigators of human error will gain an appreciation of the literature on error, with numerous references to both scientific research and investigative reports in a wide variety of applications, from airplane accidents, to bus accidents, to bonfire disasters. Based on the author's extensive experience as an accident investigator and instructor of both aircraft accident investigation techniques and human factors psychology, it reviews recent human factors literature, summarizes major transportation accidents, and shows how to investigate the types of errors that typically occur in high risk industries. It presents a model of human error causation influenced largely by James Reason and Neville Moray, and relates it to error investigations with step-by-step guidelines for data collection and analysis that investigators can readily apply as needed. This second edition of Investigating Human Error has been brought up to date throughout, with pertinent recent accidents and safety literature integrated. It features new material on fatigue, distraction (eg mobile phone and texting) and medication use. It also now explores the topics of corporate culture, safety culture and safety management systems. Additionally the second edition considers the effects of the reduction in the number of major accidents on investigation quality, the consequences of social changes on transportation safety (such as drinking and driving, cell phone use, etc), the contemporary role of accident investigation, and the effects of the prosecution of those involved in accidents.
Human Factors Models for Aviation Accident Analysis and Prevention by Thomas G.C. Griffin,Mark S. Young,Neville A. Stanton Pdf
The investigation and modelling of aviation accident causation is dominated by linear models. Aviation is, however, a complex system and as such suffers from being artificially manipulated into non-complex models and methods. This book addresses this issue by developing a new approach to investigating aviation accident causation through information networks. These networks centralise communication and the flow of information as key indicators of a system’s health and risk. This holistic approach focuses on the system environment, the activity that takes place within it, the strategies used to conduct this activity, the way in which the constituent parts of the system (both human and non-human) interact and the behaviour required. Each stage of this book identifies and expands upon the potential of the information network approach, maintaining firm focus on the overall health of a system. The book’s new model offers many potential developments and some key areas are studied in this research. Through the centralisation of barriers and information nodes the method can be applied to almost any situation. The application of Bayesian mathematics to historical data populations provides scope for studying error migration and barrier manipulation. The book also provides application of these predictions to a flight simulator study for the purposes of validation. Beyond this it also discusses the applicability of the approach to industry. Through working with a legacy airline the methods discussed are used as the basis for a new and prospective safety management system.
Guide to Applying Human Factors Methods by Carlo Cacciabue Pdf
Human error plays a significant role in many accidents involving safety-critical systems, and it is now a standard requirement in both the US and Europe for Human Factors (HF) to be taken into account in system design and safety assessment. This book will be an essential guide for anyone who uses HF in their everyday work, providing them with consistent and ready-to-use procedures and methods that can be applied to real-life problems. The first part of the book looks at the theoretical framework, methods and techniques that the engineer or safety analyst needs to use when working on a HF-related project. The second part presents four case studies that show the reader how the above framework and guidelines work in practice. The case studies are based on real-life projects carried out by the author for a major European railway system, and in collaboration with international companies such as the International Civil Aviation Organisation, Volvo, Daimler-Chrysler and FIAT.
Incident Investigation and Accident Prevention in the Process and Allied Industries by Nigel Hyatt Pdf
To prevent future accidents, a complete examination of the causes and contributory factors of an accident is necessary. Stressing the need to correct these issues, Incident Investigation and Accident Prevention in the Process and Allied Industries strikes a balance between the theoretical and applied aspects of accident investigation while also addressing accident prevention. Based on the authors forty years of experience, this detailed work covers an extensive range of topics often encountered during an incident investigation. Since the scope and needs of investigations can widely vary, the author begins with an introduction that provides guidance on how to use the book. He supplies a "roadmap" of incident investigation, making the material accessible to novices yet also valuable to more seasoned investigators. Topics include: Responding to occurrence of incidents and emergency response Securing the site and handling eyewitness testimonies Notification of appropriate authorities, compliance requirements, and legal and insurance issues Internal/external incident investigation options and investigation team requirements Disassembly, gathering, screening, tagging, storing of evidence, and post-incident testing Establishing preliminary causal mechanisms and root cause determinations Multiple cause determination, incident modeling, and human error evaluation and reporting Remedial and preventative measures, lessons learned, and reconstruction and retraining Accident prevention through predictive methodologies, including pro-active measures Pre- and post-incident management Corporate structuring, attitudinal problems, and planning an accident prevention program
The Blame Machine: Why Human Error Causes Accidents by Robert Whittingham Pdf
The Blame Machine describes how disasters and serious accidents result from recurring, but potentially avoidable, human errors. It shows how such errors are preventable because they result from defective systems within a company. From real incidents, you will be able to identify common causes of human error and typical system deficiencies that have led to these errors. On a larger scale, you will be able to see where, in the organisational or management systems, failure occurred so that you can avoid them. The book also describes the existence of a 'blame culture' in many organisations, which focuses on individual human error whilst ignoring the system failures that caused it. The book shows how this 'blame culture' has, in the case of a number of past accidents, dominated the accident enquiry process hampering a proper investigation of the underlying causes. Suggestions are made about how progress can be made to develop a more open culture in organisations, both through better understanding of human error by managers and through increased public awareness of the issues. The book brings together documentary evidence from recent major incidents from all around the world and within the Rail, Water, Aviation, Shipping, Chemical and Nuclear industries. Barry Whittingham has worked as a senior manager, design engineer and consultant for the chemical, nuclear, offshore oil and gas, railway and aviation sectors. He developed a career as a safety consultant specializing in the human factors aspects of accident causation. He is a member of the Human Factors in Reliability Group, and a Fellow of the Safety and Reliability Society.
The Field Guide to Understanding 'Human Error' by Sidney Dekker Pdf
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.
Beyond Aviation Human Factors by Daniel E. Maurino,James Reason,Neil Johnston,Rob B. Lee Pdf
The authors believe that a systematic organizational approach to aviation safety must replace the piecemeal approaches largely favoured in the past, but this change needs to be preceded by information to explain why a new approach is necessary. Accident records show a flattening of the safety curve since the early Seventies: instead of new kinds of accident, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident prevention strategies, focused almost exclusively on the action or inaction’s of front-line operational personnel. The organizational model proposed by the authors is one alternative means to pursue safety and prevention strategies in contemporary aviation; it is also applicable to other production systems. The model argues for a broadened approach, which considers the influence of all organizations (the blunt end ) involved in aviation operations, in addition to individual human performance (the sharp end ). If the concepts of systems safety and organizational accidents are to be advanced, aviation management at all levels must be aware of them. This book is intended to provide a bridge from the academic knowledge gained from research, to the needs of practitioners in aviation. It comprises six chapters: the fundamentals, background and justification for an organizational accident causation model to the flight deck, maintenance and air traffic control environments. The last chapter suggest different ways to apply the model as a prevention tool which furthermore enhances organizational effectiveness. The value of the organizational framework pioneered by Professor Reason in analyzing safety in high-technology production systems is felt by his co-authors to have an enduring role to play, both now and in coming decades. Applied now in this book, it has been adopted by ICAO, IFATCA, IMO, the US National Transportation Safety Board, the Transportation Safety B
A Practical Guide to Effective Workplace Accident Investigation by Ron C. McKinnon Pdf
This book explains how accidents and high potential near-miss incidents are caused, and how to eliminate recurrences by effective accident investigation methods. It shows how to conduct an immediate and root cause analysis so that remedial measures can be taken to prevent a recurrence of similar events. The book shows how to apply the Logical Sequence Accident Investigation Method in the case studies presented. The book: Provides a practical guide to accident causes, investigation and prevention. Explains immediate and root causes in detail. Gives a number of problem-solving methods for the accident investigator to use. Introduces the Logical Sequence Accident Investigation Method. Provides a practical accident investigation evaluation system. The book discusses important topics including hazard identification and risk assessment, workplace health and safety, accident causation and prevention theories, the updated accident domino sequence, as well as safety management system standards and controls. The text is primarily written for professionals and graduate students in the fields of occupational health and safety, ergonomics and human factors engineering.
