Investigating Human Error

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.

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. Features include: - an easy to follow step by step approach to conducting error investigations that even those new to the field can readily apply. - summaries of recent transportation accidents and human factors literature and relates them to the cause of human error in accidents. - an approach to investigating human error that will be of interest to both human factors psychology and industrial engineering students and instructors, as well as investigators of accidents in aviation, mass transportation, nuclear power, or any industry that is to the adverse effects of error. Based on the author's over 18 years of 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 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.

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.

When faced with a ’human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. 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. Building on its successful predecessors, the third edition of The Field Guide to Understanding ’Human Error’ will help you understand a new way of dealing with a perceived 'human error' problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a ’human error’ problem, abandon the fallacy of a quick fix. Read this book.

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.