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.




Beyond Human Error


Book Description

A ground-breaking new book, Beyond Human Error: Taxonomies and Safety Science deconstructs the conventional concept of human error and provides a whole new way of looking at accidents and how they might be prevented. The majority of accidents and incidents are caused, at some level, by human error. This text provides an introduction to this key field as well as a broad background to the subject. Incorporating the sociology of disaster and accidents into a practical framework, it offers a new paradigm for the subject. The authors address the roots ofhuman error in the Western tradition and discuss the history of human error studies, human factors, and ergonomics, exploring hidden assumptions that have colored past research. They include current methodologies of experimental design, new paradigms, and outlines situated and distributed cognition models, and more useful intervention strategies.




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.




Human Errors


Book Description

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




Managing the Risks of Organizational Accidents


Book Description

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.




Beyond the Checklist


Book Description

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.




Human Error


Book Description

This 1991 book is a major theoretical integration of several previously isolated literatures looking at human error in major accidents.




Set Phasers on Stun


Book Description




Safety Differently


Book Description

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




Descartes' Error


Book Description

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.