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E-raamat: Investigating Human Error: Incidents, Accidents, and Complex Systems, Second Edition

  • Formaat: PDF+DRM
  • Ilmumisaeg: 16-Mar-2017
  • Kirjastus: CRC Press
  • Keel: eng
  • ISBN-13: 9781317113119
  • Formaat - PDF+DRM
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  • Formaat: PDF+DRM
  • Ilmumisaeg: 16-Mar-2017
  • Kirjastus: CRC Press
  • Keel: eng
  • ISBN-13: 9781317113119

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In this book the author applies contemporary error theory to the needs of investigators and of anyone attempting to understand why someone made a critical error, how that error led to an incident or accident, and how to prevent such errors in the future. Students and investigators of human error will gain an appreciation of the literature on error, with numerous references to both scientific research and investigative reports in a wide variety of applications, from airplane accidents, to bus accidents, to bonfire disasters. Based on the author's extensive experience as an accident investigator and instructor of both aircraft accident investigation techniques and human factors psychology, it reviews recent human factors literature, summarizes major transportation accidents, and shows how to investigate the types of errors that typically occur in high risk industries. It presents a model of human error causation influenced largely by James Reason and Neville Moray, and relates it to error investigations with step-by-step guidelines for data collection and analysis that investigators can readily apply as needed. This second edition of Investigating Human Error has been brought up to date throughout, with pertinent recent accidents and safety literature integrated. It features new material on fatigue, distraction (eg mobile phone and texting) and medication use. It also now explores the topics of corporate culture, safety culture and safety management systems. Additionally the second edition considers the effects of the reduction in the number of major accidents on investigation quality, the consequences of social changes on transportation safety (such as drinking and driving, cell phone use, etc), the contemporary role of accident investigation, and the effects of the prosecution of those involved in accidents.

Arvustused

"This is an extremely important book, one that literally can save lives. For decades, I've argued that blaming an accident was on "human error" is not helpful. It is necessary to understand the root causes (invariably plural) and fix those, otherwise the errors continue. Often the fault lies in design, either of the system or the procedures, but there are a multitude of potential underlying, causes. Barry Strauch's book discusses these issues and provides detailed, valuable guidelines for investigating incidents with the goal, not of finding blame, but of preventing future recurrence." Don Norman, University of California, San Diego Design Lab Author of "Design of Everyday Things" Comments on previous edition: ...essential reading for the professional investigator and the serious student of the subject. Strauch is commendably thorough. Do not be discouraged from buying the book because you do not work in aviation. In fact, reading about accidents in other industries we see the causes more clearly as we are not involved.' Industrial Safety Magazine 'It is always exciting to receive new books from Ashgate in the sure expectancy of new findings and fresh interpretation...as hard to put down as a crime detection thriller, with carefully researched case histories revealing disastrous sequences of human error, maladministration and criminal neglect far stranger than fiction. This is an important and valuable book...' The RoSPA Occupational Safety and Health Journal

"This is an extremely important book, one that literally can save lives. For decades, I've argued that blaming an accident was on "human error" is not helpful. It is necessary to understand the root causes (invariably plural) and fix those, otherwise the errors continue. Often the fault lies in design, either of the system or the procedures, but there are a multitude of potential underlying, causes. Barry Strauch's book discusses these issues and provides detailed, valuable guidelines for investigating incidents with the goal, not of finding blame, but of preventing future recurrence." Don Norman, University of California, San Diego Design Lab Author of "Design of Everyday Things"

Foreword to Second Edition xv
Foreword to First Edition xxi
Preface to Second Edition xxvii
Preface to First Edition xxix
Author xxxiii
1 Introduction
1(12)
Introduction
1(1)
The Crash of ValuJet Flight 592
2(3)
Investigating Error
5(1)
Outline of the Book
6(2)
References
8(5)
Section I Errors and Complex Systems
2 Errors, Complex Systems, Accidents, and Investigations
13(26)
Operators and Complex Systems
13(4)
Complex Systems
14(1)
Operators
15(1)
Normal Accidents and Complex Systems
15(2)
Human Error
17(1)
Theories of Error
17(7)
Freud
18(1)
Heinrich
18(1)
Norman
19(1)
Rasmussen
19(1)
Reason
20(2)
What Is Error
22(1)
Error Taxonomies
23(1)
Incidents, Accidents, and Investigations
24(7)
Incidents and Accidents
24(1)
Process Accidents
25(1)
Legal Definitions
26(1)
Investigations
27(4)
From Antecedent to Error to Accident
31(4)
Assumptions
31(1)
General Model of Human Error Investigation
32(2)
Antecedents
34(1)
Antecedents and Errors
34(1)
Summary
35(1)
References
36(3)
3 Analyzing the Data
39(26)
Introduction
39(1)
Investigative Methodology
39(4)
Ex Post Facto Designs
40(1)
Imprecision
41(1)
An Illustration
42(1)
Analysis Objectives
43(1)
Assessing the Quality of the Data
43(3)
Internal Consistency
43(2)
Sequential Consistency
45(1)
Data Value
46(1)
Relevance
46(1)
Quantity
47(1)
Identifying the Errors
47(3)
The Sequence of Occurrences
47(2)
The Error or Errors
49(1)
Assessing the Relationship of Antecedents to Errors
50(3)
Inferring a Relationship
50(1)
Statistical Relationship
50(1)
Relating Antecedents to Errors
51(1)
Counterfactual Questions
52(1)
Multiple Antecedents
53(4)
Cumulative Influence
53(1)
Interacting Antecedents
54(2)
Concluding the Search for Antecedents
56(1)
Recommendations
57(2)
Summary
59(1)
References
60(5)
Section II Antecedents
4 Equipment
65(20)
Introduction
65(1)
Visual Information
66(3)
The Number of Displays
66(1)
Organization and Layout
67(1)
Conspicuity
68(1)
Interpretability
68(1)
Trend Portrayal
69(1)
Aural Information
69(5)
Conspicuity
70(1)
Distractibility
70(1)
Accuracy
71(1)
Uniqueness
71(1)
Relative Importance
72(2)
Kinesthetic/Tactile Alerts
74(1)
Controls
74(5)
Accessibility and Location
75(1)
Direction of Movement and Function
75(1)
Mode Errors
75(1)
Shape
76(1)
Placement
76(1)
Standardization
77(1)
Keyboard Controls
78(1)
Summary
79(2)
References
81(4)
5 The Operator
85(24)
Introduction
85(1)
Physiological Factors
86(5)
General Impairment
86(1)
Illness
86(2)
Alcohol and Drugs of Abuse
88(2)
Specific Impairment
90(1)
Behavioral Antecedents
91(9)
The Company's Role
92(1)
Fatigue
92(3)
Causes of Fatigue
95(1)
Investigating Fatigue
96(1)
Preventing Fatigue
97(1)
Stress
98(1)
Person-Related Stress
99(1)
System-Induced Stress
100(1)
Case Study
100(2)
Summary
102(3)
References
105(4)
6 The Company
109(18)
Introduction
109(1)
Organizations
109(6)
Hiring
110(1)
Skills, Knowledge, and Predicted Performance
110(1)
The Number of Operators
111(1)
Training
112(1)
Training Content
112(1)
Instructional Media
113(1)
Costs versus Content
114(1)
Procedures
114(1)
General versus Specific
115(1)
Oversight
115(4)
New Operators
116(1)
Experienced Operators
117(1)
"Good" Procedures
118(1)
Formal Oversight Systems
119(2)
Line Operations Safety Audit
119(1)
Flight Operations Quality Assurance
119(1)
Safety Management Systems
120(1)
Company Errors
121(1)
Case Study
122(1)
Summary
123(2)
References
125(2)
7 The Regulator
127(10)
Introduction
127(1)
What Regulators Do
128(4)
Regulator Activities
129(1)
Enacting Rules
130(1)
Enforcing Rules
131(1)
Case Study
132(3)
Summary
135(1)
References
136(1)
8 Culture
137(16)
Introduction
137(2)
National Culture
139(3)
National Cultural Antecedents and Operator Error
142(2)
Organizational Culture
144(3)
Safety Culture
144(1)
Company Practices
145(2)
High Reliability Companies
147(1)
Organizational Cultural Antecedents and Operator Error
147(1)
Summary
148(1)
References
149(4)
9 Operator Teams
153(22)
Introduction
153(1)
What Makes Effective Teams
154(2)
Leadership
154(1)
Teamwork
155(1)
Team Errors
156(2)
Operator Team Errors
158(3)
Failing to Notice or Respond to Another's Errors
158(1)
Excessively Relying on Others
158(1)
Inappropriately Influencing the Actions or Decisions of Others
159(1)
Failing to Delegate Team Duties and Responsibilities
160(1)
Operator Team: Antecedents to Error
161(5)
Equipment
162(1)
Operator
162(1)
Company
162(1)
Number of Operators
163(1)
Team Structure
163(1)
Team Stability
164(1)
Leadership Quality
165(1)
Cultural Factors
165(1)
Case Study
166(2)
Summary
168(1)
References
169(6)
Section III Sources of Data
10 Electronic Data
175(14)
Types of Recorders
175(4)
Audio/Video Recorders
176(1)
System-State Recorders
176(1)
Other Electronic Data
177(2)
System Recorder Information
179(7)
Audio Recorders
179(4)
The Equipment
183(1)
System-State Recorders
184(1)
Integrating Information from Multiple Recorders
184(2)
Assessing the Value of Recorded Data
186(1)
Audio Recorder Data
186(1)
System-State Recorder Data
186(1)
Summary
186(1)
References
187(2)
11 Interviews
189(18)
Memory Errors
189(2)
Interviewees and Their Concerns
191(1)
Eyewitnesses
191(1)
System Operators
192(1)
Those Familiar with Operators and Critical System Elements
192(1)
Information Sought
192(2)
Eyewitnesses
193(1)
Operators
193(1)
Those Familiar with Critical System Elements
194(1)
The Cognitive Interview
194(4)
Rapport
195(1)
Asking Questions
196(1)
False Responses
197(1)
Finding, Scheduling, and Selecting a Location for the Interviews
198(2)
Eyewitnesses
198(1)
Operators
198(1)
Those Familiar with Critical System Elements
199(1)
Administrative Concerns
200(2)
The Interview Record
200(1)
Operator Team Members
201(1)
Multiple Interviewers
201(1)
Information to Provide Interviewees
202(1)
Concluding the Interview
202(1)
Interpreting Interview Data
202(1)
Eyewitnesses
202(1)
Operators
203(1)
Those Familiar with Critical System Elements
203(1)
Summary
203(3)
References
206(1)
12 Written Documentation
207(12)
Introduction
207(1)
Documentation
207(4)
Company-Maintained Documentation
208(1)
Personnel Records
208(1)
Training Records
208(1)
Medical Records
209(1)
Documentation Not Maintained by the Company
210(1)
Information from Legal Proceedings
210(1)
Family-Related Information
210(1)
Driving History
210(1)
Information Value
211(2)
Quantity
211(1)
Collection Frequency and Regularity
212(1)
Length of Time Since Collected
212(1)
Reliability
212(1)
Validity
213(1)
Changes in Written Documentation
213(1)
Stable Characteristics
213(1)
Organizational Factors
214(1)
Summary
214(2)
References
216(3)
Section IV Issues
13 Maintenance and Inspection
219(18)
Introduction
219(1)
Maintenance Tasks
220(6)
Interpret and Diagnose
221(3)
Act
224(1)
Evaluate
224(2)
The Maintenance Environment
226(3)
Lighting
226(1)
Noise
227(1)
Environment
227(1)
Accessibility
227(1)
Tools and Parts
228(1)
Time Pressure
228(1)
Case Study
229(3)
Summary
232(3)
References
235(2)
14 Situation Awareness and Decision Making
237(22)
Introduction
237(1)
Situation Assessment and Situation Awareness
238(5)
Situation Awareness: Operator Elements
240(2)
Situation Awareness: Equipment Elements
242(1)
Obtaining or Losing Situation Awareness
243(2)
Obtaining Situation Awareness
243(1)
Losing Situation Awareness
244(1)
Decision Making
245(5)
Classical Decision Making
245(1)
Naturalistic Decision Making
246(1)
Heuristics and Biases
247(1)
Errors Involving Naturalistic Decision Making
248(2)
Decision-Making Quality versus Decision Quality
250(1)
Case Study
250(4)
Information Available
251(3)
Summary
254(1)
References
255(4)
15 Automation
259(18)
Introduction
259(2)
Automation
261(1)
Automation Advantages and Disadvantages
262(7)
Benefits
262(1)
Shortcomings
263(6)
Automation-Related Errors
269(1)
Case Study
270(2)
The Navigation System
270(1)
The Accident
271(1)
Summary
272(1)
References
273(4)
16 Case Study
277(20)
Introduction
277(1)
The Accident
277(1)
Background
278(2)
The Evidence
280(4)
The Pilots
280(2)
The Approach to San Francisco
282(2)
The Error
284(1)
Antecedents to Error
285(6)
Operator Antecedents: Experience
286(1)
Operator Antecedents: Fatigue
287(1)
Equipment Antecedents: Airplane System Complexity and Automation Opacity
287(2)
Equipment Antecedents: Equipment Information
289(1)
Company Antecedents: Automation Policy
289(2)
Antecedents and Errors
291(1)
Relationships between Antecedents and Errors
291(1)
Terminating the Search for Antecedents
291(1)
Recommendations
292(1)
Summary
293(1)
References
294(3)
17 Final Thoughts
297(6)
Investigative Proficiency
298(1)
Criteria
298(1)
Models of Error, Investigations, and Research
299(2)
Research and Investigations
300(1)
Quick Solutions
301(1)
Conclusions
301(1)
References
301(2)
Index 303
Barry Strauch has lectured and taught human factors, accident investigation techniques, and human error to accident investigators, graduate students, and government and industry officials throughout the world. He is an adjunct faculty member of the psychology department of George Mason University in Fairfax, Virginia. He has been with the National Transportation Safety Board for more than 30 years as a human performance investigator, major aircraft accident investigator in charge, chief of the human performance division and, currently, National Resource Specialist - Human Factors. He has investigated accidents in all major transportation modes, involving vehicles ranging from passenger trains, to Boeing 747s, to nuclear attack submarines. He earned a PhD in educational psychology from the Pennsylvania State University and holds a commercial pilot certificate, with an instrument aeroplane rating.