The Field Guide to Understanding Human Error

Front Cover
Ashgate Publishing, Ltd., 2006 - Technology & Engineering - 236 pages
When faced with a human error problem, you may be tempted to ask 'Why didn't they watch out better? How could they not have noticed?'. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. These are all expressions of 'The Bad Apple Theory', where you believe your system is basically safe if it were not for those few unreliable people in it. This old view of human error is increasingly outdated and will lead you nowhere. The new view, in contrast, understands that a human error problem is actually an organizational problem. Finding a 'human error' by any other name, or by any other human, is only the beginning of your journey, not a convenient conclusion. The new view recognizes that systems are inherent trade-offs between safety and other pressures (for example: production). People need to create safety through practice, at all levels of an organization. Breaking new ground beyond its successful predecessor, The Field Guide to Understanding Human Error guides you through the traps and misconceptions of the old view. It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language. But it also helps you look forward. It suggests how to apply the new view in building your safety department, handling questions about accountability, and constructing meaningful countermeasures. It even helps you in getting your organization to adopt the new view and improve its learning from failure.
 

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User Review  - MikePearce - LibraryThing

This book is an absolute must read for anyone "in charge of" or responsible for people. Superb view on "human error". Read full review

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User Review  - librarymary09 - LibraryThing

Fascinating and very interesting! Read full review

Contents

The Bad Apple Theory
1
The New View of Human Error
15
The Hindsight Bias
21
Put Data in Context
29
They Should Have
39
Trade Indignation for Explanation
45
Sharp or Blunt End?
59
You Cant Count Errors
65
Leave a Trace
119
So What Went Wrong?
135
Look into the Organization
159
Making Recommendations
173
Abandon the Fallacy of a Quick Fix
183
What about People s Own Responsibility?
195
Making Your Safety Department Work
205
How to Adopt the New View
215

Cause is Something You Construct
73
What is Your Accident Model?
81
Human Factors Data
93
Build a Timeline
101
Reminders for in the Rubble
225
Index
231
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About the author (2006)

Sidney Dekker is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia. Previously Professor at Lund University, Sweden, and Director of the Leonardo Da Vinci Center for Complexity and Systems Thinking there, he gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has worked in New Zealand, the Netherlands and England, been Senior Fellow at Nanyang Technological University in Singapore, Visiting Academic in the Department of Epidemiology and Preventive Medicine, Monash University in Melbourne, and Professor of Community Health Science at the Faculty of Medicine, University of Manitoba in Canada. Sidney is author of several best-selling books on system failure, human error, ethics and governance. He has been flying the Boeing 737NG part-time as airline pilot for the past few years. The OSU Foundation in the United States awards a yearly Sidney Dekker Critical Thinking Award..

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