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 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.
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.
Ten Questions About Human Error asks the type of questions frequently posed in incident and accident investigations, people's own practice, managerial and organizational settings, policymaking, classrooms, Crew Resource Management Training, and error research. It is one installment in a larger transformation that has begun to identify both deep-rooted constraints and new leverage points of views of human factors and system safety. The ten questions about human error are not just questions about human error as a phenomenon, but also about human factors and system safety as disciplines, and where they stand today. In asking these questions and sketching the answers to them, this book attempts to show where current thinking is limited--where vocabulary, models, ideas, and notions are constraining progress. This volume looks critically at the answers human factors would typically provide and compares/contrasts them with current research insights. Each chapter provides directions for new ideas and models that could perhaps better cope with the complexity of the problems facing human error today. As such, this book can be used as a supplement for a variety of human factors courses.
This book is a set of new skills written for the managers that drive safety in their workplace. This is Human Performance theory made simple. If you are starting a new program, revamping an old program, or simply interested in understanding more about safety performance, this guide will be extremely helpful.
This book provides an overview of, and practical guidance on, the range of human factors (HF) methods that can be used for the purposes of accident analysis and investigation in complex sociotechnical systems. Human Factors Methods and Accident Analysis begins with an overview of different accident causation models and an introduction to the concepts of accident analysis and investigation. It then presents a discussion focussing on the importance of, and difficulties associated with, collecting appropriate data for accident analysis purposes. Following this, a range of HF-based accident analysis methods are described, as well as step-by-step guidance on how to apply them. To demonstrate how the different methods are applied, and what the outputs are, the book presents a series of case study applications across a range of safety critical domains. It concludes with a chapter focussing on the data challenges faced when collecting, coding and analysing accident data, along with future directions in the area. Human Factors Methods and Accident Analysis is the first book to offer a practical guide for investigators, practitioners and researchers wishing to apply accident analysis methods. It is also unique in presenting a series of novel applications of accident analysis methods, including HF methods not previously used for these purposes (e.g. EAST, critical path analysis), as well as applications of methods in new domains.
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
This title was first published in 2002: This volume presents a method to investigate the human performance issues associated with an accident or incident, with a detailed discussion of the types of data to collect, and methods of collecting and analyzing data. The book should be of interest to accident/incident investigators, specialists in nuclear, chemical processing, aviation and other critical industries, safety experts, researchers and students in the field of human error, human factors, ergonomics and industrial engineering, and government agencies for regulation, health and safety.
Almost all the major accident investigations--Texas City, Piper Alpha, the Phillips 66 explosion, Feyzin, Mexico City--show human error as the principal cause, either in design, operations, maintenance, or the management of safety. This book provides practical advice that can substantially reduce human error at all levels. In eight chapters--packed with case studies and examples of simple and advanced techniques for new and existing systems--the book challenges the assumption that human error is "unavoidable." Instead, it suggests a systems perspective. This view sees error as a consequence of a mismatch between human capabilities and demands and inappropriate organizational culture. This makes error a manageable factor and, therefore, avoidable.
