The Field Guide to Understanding Human Error
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 This old view of human error is increasingly outdated and will lead you nowhere.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.
What people are saying - Write a review
LibraryThing ReviewUser 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
LibraryThing ReviewUser Review - librarymary09 - LibraryThing
Fascinating and very interesting! Read full review
The New View of Human Error
Put Data in Context
Trade Indignation for Explanation
Sharp or Blunt End?
Cause is Something You Construct
Human Factors Data
Leave a Trace
Other editions - View all
accident accountable actions activities actually aircraft airline approach assessments automation become begin behavior better called cause Chapter circumstances comes complex Computers context continue create crew critical deal decisions difficult effect entire evidence example exist explain fact factors failure Figure flight goals happened hindsight human error incident indications individual inside involved keep kind knowledge label landing language leave limited look loss means mishap operators organization organizational outcome people's performance person pilots possible practice present pressures probably problem procedures production question reasons recommendations responsibility result risk rules safe safety sense sequence of events situation sources story talk tasks things trace trouble trying turn typically understand understand human error View wrong