Download or read book Behind Human Error written by David Woods and published by CRC Press. This book was released on 2017-09-18 with total page 495 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 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 Human Errors written by Nathan H. Lents and published by HarperCollins. This book was released on 2018-05-01 with total page 255 pages. Available in PDF, EPUB and Kindle. Book excerpt: A biology professor’s “funny, fascinating” tour of the physical imperfections—from faulty knees to junk DNA—that make us human (Discover). We humans like to think of ourselves as highly evolved creatures. But if we are supposedly evolution’s greatest creation, why do we have such bad knees? Why do we catch head colds so often—two hundred times more often than a dog does? How come our wrists have so many useless bones? Why is the vast majority of our genetic code pointless? And are we really supposed to swallow and breathe through the same narrow tube? Surely there’s been some kind of mistake? As professor of biology Nathan H. Lents explains in Human Errors, our evolutionary history is indeed nothing if not a litany of mistakes, each more entertaining and enlightening than the last. The human body is one big pile of compromises. But that is also a testament to our greatness: as Lents shows, humans have so many design flaws precisely because we are very, very good at getting around them. A rollicking, deeply informative tour of humans’ four-billion-year-and-counting evolutionary saga, Human Errors both celebrates our imperfections and offers an unconventional accounting of the cost of our success. “An insightful and entertaining romp through the myriad ways in which the human body falls short of an engineering ideal—and the often-surprising reasons why.” —Ian Tattersall, author of The Monkey in the Mirror
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 Beyond Human Error written by Brendan Wallace and published by CRC Press. This book was released on 2016-04-19 with total page 282 pages. Available in PDF, EPUB and Kindle. Book excerpt: A ground-breaking new book, Beyond Human Error: Taxonomies and Safety Science deconstructs the conventional concept ofhuman error and provides a whole new way of looking at accidents and how they might be prevented. Based on research carried out in the rail, nuclear, and defense industries, the authors show how, by concentrating solely on
Download or read book Managing the Risks of Organizational Accidents written by James Reason and published by Routledge. This book was released on 2016-01-29 with total page 272 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.
Download or read book Beyond Aviation Human Factors written by Daniel E. Maurino and published by Routledge. This book was released on 2017-03-02 with total page 165 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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
Download or read book Beyond the Checklist written by Suzanne Gordon and published by Cornell University Press. This book was released on 2012-11-20 with total page 279 pages. Available in PDF, EPUB and Kindle. Book excerpt: The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel. The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, this book demonstrates how CRM can be adapted, more widely and effectively, to health care delivery. The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.They infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.
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 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 Set Phasers on Stun written by Steven Michael Casey and published by . This book was released on 1993 with total page 232 pages. Available in PDF, EPUB and Kindle. Book excerpt:
Download or read book Beyond Blame written by Dave Zwieback and published by "O'Reilly Media, Inc.". This book was released on 2015-10-07 with total page 92 pages. Available in PDF, EPUB and Kindle. Book excerpt: "IT veteran Dave Zweiback describes an incident that threatens the very existence of a large financial institution, and the counterintuitive steps its leadership took to stop the downward spiral. Their novel approach is grounded in proven concepts from complexity science, resilience engineering, human factors, cognitive science, and organizational psychology. It allows us to identify the underlying conditions for failure, and make our systems (and organizations) safer and more resilient."--Page 4 of cover
Download or read book Beyond Measure written by Margaret Heffernan and published by Simon and Schuster. This book was released on 2015-05-05 with total page 128 pages. Available in PDF, EPUB and Kindle. Book excerpt: Foundational introduction to the concept that organizations create major impacts by making small changes.
Download or read book To Err Is Human written by Institute of Medicine and published by National Academies Press. This book was released on 2000-03-01 with total page 312 pages. Available in PDF, EPUB and Kindle. Book excerpt: Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
Download or read book Organizational Accidents Revisited written by Professor James Reason and published by Ashgate Publishing, Ltd.. This book was released on 2016-01-28 with total page 195 pages. Available in PDF, EPUB and Kindle. Book excerpt: Managing the Risks of Organizational Accidents introduced the notion of an ‘organizational accident’. These are rare but often calamitous events that occur in complex technological systems operating in hazardous circumstances. They stand in sharp contrast to ‘individual accidents’ whose damaging consequences are limited to relatively few people or assets. Although they share some common causal factors, they mostly have quite different causal pathways. The frequency of individual accidents - usually lost-time injuries - does not predict the likelihood of an organizational accident. The book also elaborated upon the widely-cited Swiss Cheese Model. Organizational Accidents Revisited extends and develops these ideas using a standardised causal analysis of some 10 organizational accidents that have occurred in a variety of domains in the nearly 20 years that have passed since the original was published. These analyses provide the ‘raw data’ for the process of drilling down into the underlying causal pathways. Many contributing latent conditions recur in a variety of domains. A number of these - organizational issues, design, procedures and so on - are examined in close detail in order to identify likely problems before they combine to penetrate the defences-in-depth. Where the 1997 book focused largely upon the systemic factors underlying organisational accidents, this complementary follow-up goes beyond this to examine what can be done to improve the ‘error wisdom’ and risk awareness of those on the spot; they are often the last line of defence and so have the power to halt the accident trajectory before it can cause damage. The book concludes by advocating that system safety should require the integration of systemic factors (collective mindfulness) with individual mental skills (personal mindfulness).
Download or read book Guidelines for Preventing Human Error in Process Safety written by CCPS (Center for Chemical Process Safety) and published by John Wiley & Sons. This book was released on 2010-08-13 with total page 416 pages. Available in PDF, EPUB and Kindle. Book excerpt: Almost all the major accident investigations--Texas City, Piper Alpha, the Phillips 66 explosion, Feyzin, Mexico City--show human error as the principal cause, either in design, operations, maintenance, or the management of safety. This book provides practical advice that can substantially reduce human error at all levels. In eight chapters--packed with case studies and examples of simple and advanced techniques for new and existing systems--the book challenges the assumption that human error is "unavoidable." Instead, it suggests a systems perspective. This view sees error as a consequence of a mismatch between human capabilities and demands and inappropriate organizational culture. This makes error a manageable factor and, therefore, avoidable.
Download or read book Descartes Error written by Antonio Damasio and published by Penguin. This book was released on 2005-09-27 with total page 338 pages. Available in PDF, EPUB and Kindle. Book excerpt: Since Descartes famously proclaimed, "I think, therefore I am," science has often overlooked emotions as the source of a person’s true being. Even modern neuroscience has tended, until recently, to concentrate on the cognitive aspects of brain function, disregarding emotions. This attitude began to change with the publication of Descartes’ Error in 1995. Antonio Damasio—"one of the world’s leading neurologists" (The New York Times)—challenged traditional ideas about the connection between emotions and rationality. In this wondrously engaging book, Damasio takes the reader on a journey of scientific discovery through a series of case studies, demonstrating what many of us have long suspected: emotions are not a luxury, they are essential to rational thinking and to normal social behavior.
