Investigating Human Error Incidents Accidents And Complex Systems

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.

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.

One of the primary applications of human factors engineering is in the aviation domain, and the importance of human factors has never been greater as U.S. and European authorities seek to modernize the air transportation system through the introduction of advanced automation. This handbook provides regulators, practitioners, researchers, and educators a comprehensive resource for understanding and applying human factors to air transportation.

In an approach that combines coverage of safety and human error into a single volume, Safety and Human Error in Engineering Systems eliminates the need to consult many different and diverse sources for those who need information about both topics. The book begins with an introduction to aspects of safety and human error and a discussion of mathematical concepts that builds understanding of the material presented in subsequent chapters. The author describes the methods that can be used to perform safety and human error analysis in engineering systems and includes examples, along with their solutions, as well as problems to test reader comprehension. He presents a total of ten methods considered useful for performing safety and human error analysis in engineering systems. The book also covers safety and human error transportation systems, medical systems, and mining equipment as well as robots and software. Nowadays, engineering systems are an important element of the world economy as each year billions of dollars are spent to develop, manufacture, and operate various types of engineering systems around the globe. A rise in accidental deaths has put the spotlight on the role human error plays in the safety and failure of these systems. Written by an expert in various aspects of healthcare, engineering management, design, reliability, safety, and quality, this book provides tools and techniques for improving engineering systems with respect to human error and safety.

Synthèse unique en langue française, Modéliser les accidents et les catastrophes industrielles : la méthode STAMP est le fruit d’un travail de recherche sur les modèles d’accident au sein des systèmes, qu’ils soient techniques et/ou sociaux. Cet ouvrage décrit les principales grandes théories, modèles et approches mobilisables pour comprendre, évaluer et mettre en place une démarche de prévention des accidents et de gestion des risques au sein de systèmes sociotechniques. Il présente ainsi tous les éléments nécessaires à la compréhension des modèles d’accident : définitions, objectifs, cadres théoriques et scientifiques, limites et développements, etc... L’ouvrage aborde l’accident selon une approche systémique, notamment selon la théorie générale des systèmes de Bertalanffy. Puis il propose une étude du modèle STAMP et de la technique d’analyse des dangers STPA à travers sa mise en application au sein d’un système socio-technique industriel de traitement de sédiments contaminés, en vue d’en évaluer la sécurité et d’en améliorer la performance. Clair et concis, il permet ainsi : de connaître les principaux modèles d’accident existants et de les comprendre ; d’appréhender la modélisation d’accident comme un outil essentiel de compréhension et d’analyse des interactions entre les différents éléments d’un système et donc de son comportement ; d’acquérir et d’approfondir ses connaissances sur le modèle d’accident STAMP ainsi que sur son application au sein de systèmes socio-techniques. Modéliser les accidents et les catastrophes industrielles : la méthode STAMP s’adresse à tous les professionnels de la sécurité souhaitant consolider leur connaissance des évaluations de la sécurité ou des enquêtes sur les accidents au sein des systèmes socio-techniques.

Each year billions of dollars are being spent in the area of nuclear power generation to design, construct, manufacture, operate, and maintain various types of systems around the globe. Many times these systems fail due to safety, reliability, human factors, and human error related problems. The main objective of this book is to combine nuclear power plant safety, reliability, human factors, and human error into a single volume for those individuals that work closely during the nuclear power plant design phase, as well as other phases, thus eliminating the need to consult many different and diverse sources in obtaining the desired information.

Most aviation accidents are attributed to human error, pilot error especially. Human error also greatly effects productivity and profitability. In his overview of this collection of papers, the editor points out that these facts are often misinterpreted as evidence of deficiency on the part of operators involved in accidents. Human factors research reveals a more accurate and useful perspective: The errors made by skilled human operators - such as pilots, controllers, and mechanics - are not root causes but symptoms of the way industry operates. The papers selected for this volume have strongly influenced modern thinking about why skilled experts make errors and how to make aviation error resilient.

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.