Preface |
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xi | |
Acknowledgements |
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xiii | |
Author |
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xv | |
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xvii | |
Introduction |
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xix | |
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Chapter 1 Why A `Competence-Based' Approach To Crew Resource Management Training? |
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1 | (22) |
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1 | (1) |
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1.2 A Short History of CRM |
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2 | (3) |
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1.3 What Does Expertise Look Like? |
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5 | (5) |
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10 | (3) |
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1.5 Developing Training Interventions |
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13 | (2) |
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1.6 Instructional Design vs Competency-based Training |
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15 | (4) |
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1.7 Understanding `Success' |
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19 | (2) |
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21 | (1) |
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21 | (2) |
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Chapter 2 Thinking About Failure |
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23 | (20) |
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23 | (2) |
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25 | (1) |
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2.3 The Building Blocks of Safety Thinking |
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25 | (4) |
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2.4 The Pelee Island Crash |
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29 | (2) |
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2.5 Linear Models of Accident Causation |
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31 | (3) |
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2.6 Normal Accident Theory (NAT) and High Reliability Organisations |
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34 | (3) |
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37 | (2) |
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2.8 Why Historical Models Are Problematic |
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39 | (1) |
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40 | (1) |
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41 | (2) |
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Chapter 3 A Systems Model Of Aviation |
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43 | (24) |
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43 | (1) |
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3.2 Systems Thinking and Safety |
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43 | (3) |
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3.3 The Structure of the Aviation System - Aviation as Hierarchical Decision-Making |
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46 | (1) |
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3.4 Behaviour within a System |
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47 | (2) |
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3.5 Pelee Island as a System |
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49 | (2) |
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3.6 Exploring Structural Elements of a Resilient System |
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51 | (5) |
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3.7 Systems and Scale Effects |
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56 | (6) |
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3.8 Systems, Drift and the Distortion of Buffering |
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62 | (3) |
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65 | (1) |
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66 | (1) |
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Chapter 4 On Being Human -- Frailties, Vulnerabilities And Their Effect On Performance |
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67 | (34) |
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67 | (1) |
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4.2 `Personality' -- How Evolution Shapes Behaviour |
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68 | (4) |
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4.3 Stress as a Biological Process |
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72 | (2) |
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4.4 Stress, Fear and `Startle' |
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74 | (1) |
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75 | (1) |
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76 | (1) |
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4.7 Acute Fatigue in Pilots |
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77 | (2) |
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4.8 Acclimatisation and Night Flying |
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79 | (1) |
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4.9 Chronic Fatigue in Airline Pilots |
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80 | (2) |
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82 | (1) |
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4.11 Anxiety and Psychological Fatigue! |
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83 | (6) |
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89 | (1) |
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4.13 Fatigue and Pilot Health |
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90 | (2) |
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4.14 Fatigue and Safety -- Cause or Risk Factor? |
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92 | (4) |
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96 | (1) |
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96 | (5) |
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Chapter 5 Doing Normal Work -- Processes At Level 1 |
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101 | (30) |
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101 | (1) |
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102 | (2) |
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5.3 Goals, Boundaries and Margins -- The Structure of Tasks |
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104 | (3) |
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5.4 Buffering and Efficacy -- The Management of Goal States |
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107 | (1) |
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5.5 Goal States and Resilience |
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108 | (1) |
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5.6 Human Information Processing |
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109 | (3) |
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5.7 Situational Awareness, Distributed Cognition and Sense-Making |
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112 | (2) |
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5.8 Performance as Approximation |
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114 | (3) |
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5.9 Acting in an Under-specified World |
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117 | (2) |
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5.10 Decision-Making as Task Management |
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119 | (3) |
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5.11 Decision-Making and Goal State Modification |
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122 | (2) |
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5.12 The Special Case of Problem-Solving |
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124 | (3) |
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5.13 Safety Drift at the Individual Level -- Behavioural Templates |
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127 | (1) |
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5.14 Conclusion -- Working at Level 1 |
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127 | (2) |
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129 | (2) |
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Chapter 6 Error As Performance Feedback |
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131 | (24) |
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131 | (1) |
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6.2 The Helios B-737 Crash Near Athens, 2005 |
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132 | (1) |
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132 | (2) |
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6.4 Slips -- Executing Trained Behaviour Patterns |
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134 | (1) |
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6.5 Lapses -- Forgetting as a part of work |
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135 | (3) |
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6.6 Mistakes -- The Failure of Rules |
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138 | (2) |
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6.7 Bringing Knowledge into Play |
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140 | (3) |
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6.8 Sense-making, Rule-based and Knowledge-based Action |
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143 | (1) |
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6.9 Performance under Normal Circumstances |
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144 | (1) |
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6.10 Factors That Shape Performance |
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145 | (1) |
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146 | (2) |
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148 | (1) |
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6.13 `Wrong Work' and Violations as Improvisations |
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149 | (2) |
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6.14 Performance Approaching the Boundary |
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151 | (3) |
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6.15 Conclusion: Errors as Signals of System Behaviour |
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154 | (1) |
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154 | (1) |
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Chapter 7 Acting In The Public Domain -- Collaboration To Achieve Operational Goals |
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155 | (26) |
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155 | (1) |
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7.2 Collaboration in a Systems Context |
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156 | (1) |
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7.3 Collaboration as Shared Decision-Making |
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157 | (4) |
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7.4 Collaboration in Normal Work |
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161 | (1) |
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7.5 Engagement as a Transitory State |
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162 | (3) |
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7.6 Control in Work Groups -- Monitoring as Collaborative Task Management |
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165 | (6) |
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7.7 Within-Group Social Dynamics |
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171 | (1) |
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7.8 Leadership -- A Special Case in Self-directed Teams? |
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172 | (4) |
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176 | (1) |
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177 | (1) |
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7.11 Behaviour between Groups |
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177 | (1) |
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178 | (1) |
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178 | (3) |
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181 | (26) |
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181 | (1) |
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8.2 The Evolution of Communication |
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181 | (1) |
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8.3 San Juan, Puerto Rico |
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182 | (1) |
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8.4 What Is `Communication'? |
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183 | (1) |
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8.5 Communication in an Aviation Context -- What It Does? |
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184 | (2) |
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186 | (2) |
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8.7 A Functional Model of Communication |
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188 | (1) |
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8.8 Exploring Communication Dynamics: Control and Verification |
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189 | (1) |
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8.9 Communication, Option Selection and Decision-Making |
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190 | (1) |
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8.10 Creating Future Plans: Shared Understanding |
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191 | (1) |
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192 | (1) |
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8.12 What `Normal' Communication Looks Like? |
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193 | (2) |
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8.13 Communication in a Systems Model |
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195 | (1) |
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8.13 Distributed Communication |
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196 | (2) |
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8.14 Communication as Information Propagation across a Network |
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198 | (2) |
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8.15 Communication as Hierarchical Control |
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200 | (3) |
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8.16 Communication, Safety Drift and Scale Law at a Systems Level |
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203 | (1) |
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204 | (1) |
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204 | (3) |
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Chapter 9 Organisational Factors -- Level 3 |
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207 | (24) |
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207 | (1) |
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208 | (1) |
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9.3 How Things Get Done in Aviation |
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209 | (3) |
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9.4 Fundamental Challenges at the Heart of Organisations |
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212 | (2) |
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9.5 Management Control and Worker Responses |
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214 | (1) |
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9.6 Control, Management Legitimacy or Chaos and Abuse? |
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215 | (2) |
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9.7 Demand and Overwork -- Employee Sickness/Absence as Resistance |
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217 | (4) |
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9.8 Delegating Control: Challenges to Autonomy -- Why Fuel Efficiency Measures Are Resisted |
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221 | (3) |
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9.9 Striving for Efficiency: Contradictions in Employee Involvement -- Why Safety Reporting Fails |
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224 | (3) |
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9.10 Do Organisations Learn? |
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227 | (1) |
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228 | (1) |
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229 | (1) |
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229 | (2) |
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Chapter 10 Facilitating Aviation -- Decision-Making At Level 4 |
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231 | (24) |
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231 | (1) |
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10.2 The Nature of Regulation |
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232 | (1) |
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10.3 Regulation as Hierarchical Control |
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233 | (2) |
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235 | (1) |
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10.5 Change Management and Regulatory Failure |
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236 | (3) |
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10.6 Failure, Capture and Crisis -- Regulators, Aircraft Manufacturers and the Construction of Safety |
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239 | (4) |
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10.7 Investigation as Feedback |
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243 | (1) |
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10.8 The Pel Air Westwind Ditching |
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244 | (1) |
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245 | (3) |
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10.10 Postscript to Pel Air |
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248 | (2) |
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10.11 Regulation, Investigation, Control and Feedback |
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250 | (1) |
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251 | (1) |
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252 | (3) |
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Chapter 11 Training For Competence |
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255 | (30) |
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255 | (1) |
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11.2 The Training Problem |
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255 | (1) |
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11.3 Assessment Frameworks and `Competence' |
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256 | (3) |
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11.4 A Systems View of Competence |
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259 | (6) |
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11.4.1 Competence as `Normal Work' |
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261 | (1) |
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11.4.2 Competence as Management of Anomalies -- Performance in Transitional States |
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262 | (2) |
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11.4.3 Competence in a Crisis -- Performance at the Boundary |
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264 | (1) |
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11.4.4 An Outline Competence Model |
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265 | (1) |
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11.5 Non-Training Interventions |
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265 | (8) |
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11.6 Are Stress and Fatigue a Special Case? |
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273 | (1) |
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11.7 Developing Training Interventions |
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274 | (6) |
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11.8 Mapping Competencies onto Training Methods |
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280 | (2) |
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282 | (1) |
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283 | (2) |
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Chapter 12 Assessment Of Performance |
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285 | (16) |
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285 | (1) |
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285 | (1) |
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286 | (2) |
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12.4 Assigning a Value to the Performance |
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288 | (3) |
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12.5 Assessors as Sources of Bias |
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291 | (1) |
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12.6 Establishing Reliability and Validity |
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292 | (3) |
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295 | (2) |
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12.8 Conducting the Assessment |
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297 | (2) |
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299 | (1) |
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300 | (1) |
Index |
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301 | |