The Blame Machine: Why Human Error Causes Accidents


Book Description

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.




A Human Error Approach to Aviation Accident Analysis


Book Description

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.




The Field Guide to Human Error Investigations


Book Description

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


Book Description

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.




Advanced Safety Management Focusing on Z10 and Serious Injury Prevention


Book Description

Learn how to improve the effectiveness of safety and health management systems by adopting ANSI Z10 provisions and avoid serious workplace injuries. This reference addresses specific provisions, including risk assessment methods and prioritization; applying a prescribed hierarchy of controls; implementing safety design reviews; and more. It also explains how to integrate best practices for the prevention of serious injuries in your workplace. See how implementing the ANSI Z10 standard can enhance your company’s productivity, cost efficiency, and quality.




Safety and Human Error in Engineering Systems


Book Description

In an approach that combines coverage of safety and human error into a single volume, Safety and Human Error in Engineering Systems eliminates the need to consult many different and diverse sources for those who need information about both topics. The book begins with an introduction to aspects of safety and human error and a discussion of mathemat




Advanced Safety Management


Book Description

Provides guidance to managers, safety professionals, educators and students on having operational risk management systems that meet the requirements of Z10. Emphasizes Management Leadership and Employee Involvement, the most important section in Z10, with particular reference to contributions that employees can make. A new provision was added to Z10 on Risk Assessment which along with Avoidance of Human Error is addressed. Revised and expanded coverage of Management of Change and The Procurement Process New chapters cover Macro Thinking – The Socio-Technical Model; Safety Professionals as Culture Change Agents; Prevention through Design, and A Primer on System Safety




There Are No Accidents


Book Description

A journalist recounts the surprising history of accidents and reveals how they’ve come to define all that’s wrong with America. We hear it all the time: “Sorry, it was just an accident.” And we’ve been deeply conditioned to just accept that explanation and move on. But as Jessie Singer argues convincingly: There are no such things as accidents. The vast majority of mishaps are not random but predictable and preventable. Singer uncovers just how the term “accident” itself protects those in power and leaves the most vulnerable in harm’s way, preventing investigations, pushing off debts, blaming the victims, diluting anger, and even sparking empathy for the perpetrators. As the rate of accidental death skyrockets in America, the poor and people of color end up bearing the brunt of the violence and blame, while the powerful use the excuse of the “accident” to avoid consequences for their actions. Born of the death of her best friend, and the killer who insisted it was an accident, this book is a moving investigation of the sort of tragedies that are all too common, and all too commonly ignored. In this revelatory book, Singer tracks accidental death in America from turn of the century factories and coal mines to today’s urban highways, rural hospitals, and Superfund sites. Drawing connections between traffic accidents, accidental opioid overdoses, and accidental oil spills, Singer proves that what we call accidents are hardly random. Rather, who lives and dies by an accident in America is defined by money and power. She also presents a variety of actions we can take as individuals and as a society to stem the tide of “accidents”—saving lives and holding the guilty to account.




Embodied Minds--technical Environments


Book Description

The deep integration of technology into our modern society forces us to rethink the relationship humans have to their surroundings. The rise of complex socio-technical systems denotes how humans and technology have entered a symbiotic relationship where the coordinated and fluent interaction between the two is a crucial condition for modern societies to function. The disharmony in the relationship between humans and technology has immediate and serious consequences. Accidents and failed operations in transport, incomprehensible user interfaces, and failure to learn from experience are all examples from everyday life, suggesting that the understanding of human-technology relationships is not sufficient. This book investigates how humans relate to technology in our modern society, and how the basic assumption of human thought and behavior guide human efforts to improve and control technology. The fact is that the skilled use of technology in expert systems and everyday life challenges the traditional conception of humans and technology as two separate elements in the analysis of work. The book shows how this dualism is evident and problematic in a wide range of areas, such as investigation of human error in accidents, case studies of innovative interface solutions, simulator training strategies, analysis of work practices in complex systems, and traffic safety research. Embodied Minds - Technical Environments supplements the ongoing effort to understand how technology can be integrated with more confidence in modern society.




Error Logic: Paving Pathways for Intelligent Error Identification and Management


Book Description

This book offers a brand-new theoretical system and relevant tools for intelligently identifying errors in the decision-making process, investigating the complexities and erring mechanisms of dysfunctional socioeconomic systems, and therefore helping design error-proof systems. The error logic is invented to pioneer a new branch for the field of logic, which can be applied to various fields including mathematics, philosophy, computer science, artificial intelligence, linguistics, management science, and systems science. Researchers, postgraduates, and undergraduates in relevant fields can use it as a reference for enhancing their understanding of the tempo-spatial dynamics and transformation of errors in complicated systems. The manuscript also provides vivid and thought-provoking examples and applications to help readers understand how to apply the concepts and theory in real socioeconomic systems.