The Field Guide To Human Error Investigations

Author : Sidney Dekker
Publisher : Routledge
Page : 137 pages
File Size : 51,9 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.

Author : Sidney Dekker
Publisher : CRC Press
Page : 250 pages
File Size : 43,5 Mb
Release : 2017-04-07
Category : Technology & Engineering
ISBN : 9781351889759

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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 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 This old view of human error is increasingly outdated and will lead you nowhere.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.

Author : Douglas A. Wiegmann,Scott A. Shappell
Publisher : Routledge
Page : 174 pages
File Size : 45,6 Mb
Release : 2017-12-22
Category : Technology & Engineering
ISBN : 9781351962353

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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.

Author : Barry Strauch
Publisher : Routledge
Page : 261 pages
File Size : 45,6 Mb
Release : 2018-05-08
Category : Social Science
ISBN : 9781351727020

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Investigating Human Error 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.

Author : Dr Todd Conklin
Publisher : Ashgate Publishing, Ltd.
Page : 192 pages
File Size : 43,8 Mb
Release : 2012-10-28
Category : Technology & Engineering
ISBN : 9781409483540

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Pre-Accident Investigations by Dr Todd Conklin Pdf

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.

Author : Sidney Dekker
Publisher : CRC Press
Page : 233 pages
File Size : 46,9 Mb
Release : 2004-12-27
Category : Technology & Engineering
ISBN : 9781410612069

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Ten Questions About Human Error by Sidney Dekker Pdf

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.

Author : David D. Woods,Sidney Dekker,Richard Cook,Leila Johannesen,Nadine Sarter
Publisher : CRC Press
Page : 292 pages
File Size : 41,8 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.

Author : Sidney Dekker
Publisher : CRC Press
Page : 131 pages
File Size : 51,6 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

Author : Sidney Dekker
Publisher : CRC Press
Page : 332 pages
File Size : 47,9 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.

Author : Professor Alan Merry,Professor Merrilyn Walton,Professor Bill Runciman
Publisher : Ashgate Publishing, Ltd.
Page : 375 pages
File Size : 49,5 Mb
Release : 2012-10-01
Category : Medical
ISBN : 9781409485001

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Safety and Ethics in Healthcare: A Guide to Getting it Right by Professor Alan Merry,Professor Merrilyn Walton,Professor Bill Runciman Pdf

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.

Author : Sidney Dekker
Publisher : CRC Press
Page : 304 pages
File Size : 41,7 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

Author : J. T. Reason
Publisher : Ashgate Publishing, Ltd.
Page : 320 pages
File Size : 50,5 Mb
Release : 2008
Category : Transportation
ISBN : 0754674002

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The Human Contribution by J. T. Reason Pdf

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.

Author : ABS Consulting,Lee N. Vanden Heuvel,Donald K. Lorenzo,Laura O. Jackson,Walter E. Hanson,James J. Rooney,David A. Walker
Publisher : Rothstein Publishing
Page : 296 pages
File Size : 45,7 Mb
Release : 2014-10-01
Category : Business & Economics
ISBN : 9781931332828

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Root Cause Analysis Handbook by ABS Consulting,Lee N. Vanden Heuvel,Donald K. Lorenzo,Laura O. Jackson,Walter E. Hanson,James J. Rooney,David A. Walker Pdf

Are you trying to improve performance, but find that the same problems keep getting in the way? Safety, health, environmental quality, reliability, production, and security are at stake. You need the long-term planning that will keep the same issues from recurring. Root Cause Analysis Handbook: A Guide to Effective Incident Investigation is a powerful tool that gives you a detailed step-by-step process for learning from experience. Reach for this handbook any time you need field-tested advice for investigating, categorizing, reporting and trending, and ultimately eliminating the root causes of incidents. It includes step-by-step instructions, checklists, and forms for performing an analysis and enables users to effectively incorporate the methodology and apply it to a variety of situations. Using the structured techniques in the Root Cause Analysis Handbook, you will: Understand why root causes are important. Identify and define inherent problems. Collect data for problem-solving. Analyze data for root causes. Generate practical recommendations. The third edition of this global classic is the most comprehensive, all-in-one package of book, downloadable resources, color-coded RCA map, and licensed access to online resources currently available for Root Cause Analysis (RCA). Called by users "the best resource on the subject" and "in a league of its own." Based on globally successful, proprietary methodology developed by ABS Consulting, an international firm with 50 years' experience in 35 countries. Root Cause Analysis Handbook is widely used in corporate training programs and college courses all over the world. If you are responsible for quality, reliability, safety, and/or risk management, you'll want this comprehensive and practical resource at your fingertips. The book has also been selected by the American Society for Quality (ASQ) and the Risk and Insurance Society (RIMS) as a "must have" for their members.

Author : David Wilcock
Publisher : Penguin
Page : 560 pages
File Size : 45,8 Mb
Release : 2011-08-23
Category : Body, Mind & Spirit
ISBN : 9781101543504

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The Source Field Investigations by David Wilcock Pdf

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.

Author : Mark Paradies,Linda Unger
Publisher : Unknown
Page : 422 pages
File Size : 44,7 Mb
Release : 2000
Category : Business & Economics
ISBN : 1893130029

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TapRooT by Mark Paradies,Linda Unger Pdf