Download or read book The Field Guide to Human Error Investigations written by Sidney Dekker and published by Routledge. This book was released on 2017-11-01 with total page 137 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book The Field Guide to Understanding Human Error written by Sidney Dekker and published by CRC Press. This book was released on 2017-04-07 with total page 250 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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 This old view of human error is increasingly outdated and will lead you nowhere.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.

Download or read book Investigating Human Error written by Barry Strauch and published by Routledge. This book was released on 2018-05-08 with total page 261 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book A Human Error Approach to Aviation Accident Analysis written by Douglas A. Wiegmann and published by Routledge. This book was released on 2017-12-22 with total page 174 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Ten Questions About Human Error written by Sidney Dekker and published by CRC Press. This book was released on 2004-12-27 with total page 233 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Behind Human Error written by David D. Woods and published by CRC Press. This book was released on 2017-09-18 with total page 292 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Pre Accident Investigations written by Dr Todd Conklin and published by Ashgate Publishing, Ltd.. This book was released on 2012-10-28 with total page 161 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Human Error written by James Reason and published by Cambridge University Press. This book was released on 1990-10-26 with total page 324 pages. Available in PDF, EPUB and Kindle. Book excerpt: This 1991 book is a major theoretical integration of several previously isolated literatures looking at human error in major accidents.

Download or read book The Human Contribution written by J. T. Reason and published by Ashgate Publishing, Ltd.. This book was released on 2008 with total page 320 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Drift into Failure written by Sidney Dekker and published by CRC Press. This book was released on 2016-12-05 with total page 332 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Second Victim written by Sidney Dekker and published by CRC Press. This book was released on 2013-03-26 with total page 131 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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

Download or read book Safety and Ethics in Healthcare A Guide to Getting it Right written by Professor Alan Merry and published by Ashgate Publishing, Ltd.. This book was released on 2012-10-01 with total page 372 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Safety Differently written by Sidney Dekker and published by CRC Press. This book was released on 2014-06-23 with total page 304 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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

Download or read book The Machine written by Lee Fang and published by The New Press. This book was released on 2013 with total page 274 pages. Available in PDF, EPUB and Kindle. Book excerpt: Before Obama took the oath of office after his historic victory, lobbyists, political hacks, oil tycoons and right-wing politicians had planned his political demise. The massive conservative infrastructure created by business groups beginning in the 1970s would not be sufficient, they concluded: in the age of Obama, something new had to be done. Written by the blogger who was the first to report on the lobbyists who staged the Tea Parties, here is a groundbreaking expose of the plans to make America conservative again.

Download or read book Malware Forensics Field Guide for Windows Systems written by Cameron H. Malin and published by Elsevier. This book was released on 2012-05-11 with total page 560 pages. Available in PDF, EPUB and Kindle. Book excerpt: Malware Forensics Field Guide for Windows Systems is a handy reference that shows students the essential tools needed to do computer forensics analysis at the crime scene. It is part of Syngress Digital Forensics Field Guides, a series of companions for any digital and computer forensic student, investigator or analyst. Each Guide is a toolkit, with checklists for specific tasks, case studies of difficult situations, and expert analyst tips that will aid in recovering data from digital media that will be used in criminal prosecution. This book collects data from all methods of electronic data storage and transfer devices, including computers, laptops, PDAs and the images, spreadsheets and other types of files stored on these devices. It is specific for Windows-based systems, the largest running OS in the world. The authors are world-renowned leaders in investigating and analyzing malicious code. Chapters cover malware incident response - volatile data collection and examination on a live Windows system; analysis of physical and process memory dumps for malware artifacts; post-mortem forensics - discovering and extracting malware and associated artifacts from Windows systems; legal considerations; file identification and profiling initial analysis of a suspect file on a Windows system; and analysis of a suspect program. This field guide is intended for computer forensic investigators, analysts, and specialists. A condensed hand-held guide complete with on-the-job tasks and checklists Specific for Windows-based systems, the largest running OS in the world Authors are world-renowned leaders in investigating and analyzing malicious code

Download or read book The Source Field Investigations written by David Wilcock and published by Penguin. This book was released on 2012-07-31 with total page 562 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Just Culture written by Sidney Dekker and published by CRC Press. This book was released on 2018-09-07 with total page 250 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.