| Foreword to Second Edition |
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xv | |
| Foreword to First Edition |
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xxi | |
| Preface to Second Edition |
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xxvii | |
| Preface to First Edition |
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xxix | |
| Author |
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xxxiii | |
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1 | (12) |
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1 | (1) |
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The Crash of ValuJet Flight 592 |
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2 | (3) |
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5 | (1) |
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6 | (2) |
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8 | (5) |
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Section I Errors and Complex Systems |
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2 Errors, Complex Systems, Accidents, and Investigations |
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13 | (26) |
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Operators and Complex Systems |
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13 | (4) |
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14 | (1) |
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15 | (1) |
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Normal Accidents and Complex Systems |
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15 | (2) |
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17 | (1) |
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17 | (7) |
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18 | (1) |
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18 | (1) |
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19 | (1) |
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19 | (1) |
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20 | (2) |
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22 | (1) |
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23 | (1) |
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Incidents, Accidents, and Investigations |
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24 | (7) |
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24 | (1) |
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25 | (1) |
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26 | (1) |
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27 | (4) |
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From Antecedent to Error to Accident |
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31 | (4) |
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31 | (1) |
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General Model of Human Error Investigation |
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32 | (2) |
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34 | (1) |
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34 | (1) |
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35 | (1) |
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36 | (3) |
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39 | (26) |
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39 | (1) |
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Investigative Methodology |
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39 | (4) |
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40 | (1) |
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41 | (1) |
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42 | (1) |
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43 | (1) |
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Assessing the Quality of the Data |
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43 | (3) |
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43 | (2) |
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45 | (1) |
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46 | (1) |
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46 | (1) |
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47 | (1) |
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47 | (3) |
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The Sequence of Occurrences |
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47 | (2) |
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49 | (1) |
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Assessing the Relationship of Antecedents to Errors |
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50 | (3) |
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50 | (1) |
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50 | (1) |
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Relating Antecedents to Errors |
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51 | (1) |
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52 | (1) |
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53 | (4) |
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53 | (1) |
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54 | (2) |
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Concluding the Search for Antecedents |
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56 | (1) |
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57 | (2) |
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59 | (1) |
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60 | (5) |
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65 | (20) |
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65 | (1) |
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66 | (3) |
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66 | (1) |
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67 | (1) |
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68 | (1) |
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68 | (1) |
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69 | (1) |
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69 | (5) |
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70 | (1) |
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70 | (1) |
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71 | (1) |
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71 | (1) |
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72 | (2) |
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Kinesthetic/Tactile Alerts |
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74 | (1) |
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74 | (5) |
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Accessibility and Location |
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75 | (1) |
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Direction of Movement and Function |
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75 | (1) |
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75 | (1) |
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76 | (1) |
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76 | (1) |
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77 | (1) |
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78 | (1) |
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79 | (2) |
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81 | (4) |
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85 | (24) |
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85 | (1) |
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86 | (5) |
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86 | (1) |
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86 | (2) |
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Alcohol and Drugs of Abuse |
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88 | (2) |
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90 | (1) |
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91 | (9) |
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92 | (1) |
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92 | (3) |
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95 | (1) |
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96 | (1) |
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97 | (1) |
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98 | (1) |
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99 | (1) |
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100 | (1) |
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100 | (2) |
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102 | (3) |
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105 | (4) |
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109 | (18) |
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109 | (1) |
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109 | (6) |
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110 | (1) |
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Skills, Knowledge, and Predicted Performance |
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110 | (1) |
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111 | (1) |
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112 | (1) |
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112 | (1) |
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113 | (1) |
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114 | (1) |
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114 | (1) |
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115 | (1) |
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115 | (4) |
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116 | (1) |
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117 | (1) |
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118 | (1) |
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119 | (2) |
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Line Operations Safety Audit |
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119 | (1) |
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Flight Operations Quality Assurance |
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119 | (1) |
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Safety Management Systems |
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120 | (1) |
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121 | (1) |
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122 | (1) |
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123 | (2) |
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125 | (2) |
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127 | (10) |
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127 | (1) |
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128 | (4) |
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129 | (1) |
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130 | (1) |
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131 | (1) |
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132 | (3) |
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135 | (1) |
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136 | (1) |
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137 | (16) |
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137 | (2) |
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139 | (3) |
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National Cultural Antecedents and Operator Error |
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142 | (2) |
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144 | (3) |
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144 | (1) |
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145 | (2) |
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High Reliability Companies |
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147 | (1) |
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Organizational Cultural Antecedents and Operator Error |
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147 | (1) |
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148 | (1) |
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149 | (4) |
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153 | (22) |
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153 | (1) |
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What Makes Effective Teams |
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154 | (2) |
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154 | (1) |
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155 | (1) |
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156 | (2) |
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158 | (3) |
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Failing to Notice or Respond to Another's Errors |
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158 | (1) |
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Excessively Relying on Others |
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158 | (1) |
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Inappropriately Influencing the Actions or Decisions of Others |
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159 | (1) |
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Failing to Delegate Team Duties and Responsibilities |
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160 | (1) |
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Operator Team: Antecedents to Error |
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161 | (5) |
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162 | (1) |
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162 | (1) |
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162 | (1) |
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163 | (1) |
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163 | (1) |
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164 | (1) |
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165 | (1) |
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165 | (1) |
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166 | (2) |
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168 | (1) |
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169 | (6) |
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Section III Sources of Data |
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175 | (14) |
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175 | (4) |
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176 | (1) |
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176 | (1) |
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177 | (2) |
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System Recorder Information |
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179 | (7) |
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179 | (4) |
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183 | (1) |
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184 | (1) |
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Integrating Information from Multiple Recorders |
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184 | (2) |
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Assessing the Value of Recorded Data |
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186 | (1) |
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186 | (1) |
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System-State Recorder Data |
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186 | (1) |
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186 | (1) |
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187 | (2) |
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189 | (18) |
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189 | (2) |
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Interviewees and Their Concerns |
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191 | (1) |
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191 | (1) |
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192 | (1) |
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Those Familiar with Operators and Critical System Elements |
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192 | (1) |
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192 | (2) |
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193 | (1) |
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193 | (1) |
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Those Familiar with Critical System Elements |
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194 | (1) |
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194 | (4) |
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195 | (1) |
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196 | (1) |
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197 | (1) |
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Finding, Scheduling, and Selecting a Location for the Interviews |
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198 | (2) |
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198 | (1) |
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198 | (1) |
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Those Familiar with Critical System Elements |
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199 | (1) |
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200 | (2) |
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200 | (1) |
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201 | (1) |
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201 | (1) |
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Information to Provide Interviewees |
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202 | (1) |
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202 | (1) |
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Interpreting Interview Data |
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202 | (1) |
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202 | (1) |
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203 | (1) |
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Those Familiar with Critical System Elements |
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203 | (1) |
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203 | (3) |
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206 | (1) |
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207 | (12) |
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207 | (1) |
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207 | (4) |
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Company-Maintained Documentation |
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208 | (1) |
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208 | (1) |
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208 | (1) |
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209 | (1) |
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Documentation Not Maintained by the Company |
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210 | (1) |
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Information from Legal Proceedings |
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210 | (1) |
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Family-Related Information |
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210 | (1) |
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210 | (1) |
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211 | (2) |
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211 | (1) |
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Collection Frequency and Regularity |
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212 | (1) |
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Length of Time Since Collected |
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212 | (1) |
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212 | (1) |
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213 | (1) |
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Changes in Written Documentation |
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213 | (1) |
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213 | (1) |
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214 | (1) |
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214 | (2) |
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216 | (3) |
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13 Maintenance and Inspection |
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219 | (18) |
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219 | (1) |
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220 | (6) |
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221 | (3) |
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224 | (1) |
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224 | (2) |
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The Maintenance Environment |
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226 | (3) |
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226 | (1) |
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227 | (1) |
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227 | (1) |
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227 | (1) |
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228 | (1) |
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228 | (1) |
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229 | (3) |
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232 | (3) |
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235 | (2) |
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14 Situation Awareness and Decision Making |
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237 | (22) |
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237 | (1) |
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Situation Assessment and Situation Awareness |
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238 | (5) |
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Situation Awareness: Operator Elements |
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240 | (2) |
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Situation Awareness: Equipment Elements |
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242 | (1) |
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Obtaining or Losing Situation Awareness |
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243 | (2) |
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Obtaining Situation Awareness |
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243 | (1) |
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Losing Situation Awareness |
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244 | (1) |
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245 | (5) |
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Classical Decision Making |
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245 | (1) |
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Naturalistic Decision Making |
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246 | (1) |
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247 | (1) |
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Errors Involving Naturalistic Decision Making |
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248 | (2) |
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Decision-Making Quality versus Decision Quality |
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250 | (1) |
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250 | (4) |
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251 | (3) |
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254 | (1) |
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255 | (4) |
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259 | (18) |
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259 | (2) |
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261 | (1) |
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Automation Advantages and Disadvantages |
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262 | (7) |
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262 | (1) |
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263 | (6) |
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Automation-Related Errors |
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269 | (1) |
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270 | (2) |
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270 | (1) |
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271 | (1) |
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272 | (1) |
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273 | (4) |
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277 | (20) |
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277 | (1) |
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277 | (1) |
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278 | (2) |
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280 | (4) |
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280 | (2) |
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The Approach to San Francisco |
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282 | (2) |
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284 | (1) |
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285 | (6) |
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Operator Antecedents: Experience |
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286 | (1) |
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Operator Antecedents: Fatigue |
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287 | (1) |
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Equipment Antecedents: Airplane System Complexity and Automation Opacity |
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287 | (2) |
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Equipment Antecedents: Equipment Information |
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289 | (1) |
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Company Antecedents: Automation Policy |
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289 | (2) |
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291 | (1) |
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Relationships between Antecedents and Errors |
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291 | (1) |
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Terminating the Search for Antecedents |
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291 | (1) |
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292 | (1) |
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293 | (1) |
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294 | (3) |
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297 | (6) |
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Investigative Proficiency |
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298 | (1) |
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298 | (1) |
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Models of Error, Investigations, and Research |
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299 | (2) |
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Research and Investigations |
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300 | (1) |
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301 | (1) |
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301 | (1) |
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301 | (2) |
| Index |
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303 | |