Behind Human Error
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Download Full-text PDF Behind Human ErrorArticle (PDF Available) · January 2010 with 337 ReadsSource: OAI1st David D Woods36.68 · The Ohio State University2nd Sidney W A Dekker26.32 · Griffith University3rd Richard Irvin Cook36.9 · KTH Royal human error quotes Institute of Technology4th Leila JohannsenAbstractYes YesDiscover the world's research10+ million members100+ million publications100k+
Human Error In Aviation
research projectsJoin for free Behind Human ErrorSecond EditionDavid D. Woods, Ohio State University, USA, Sidney Dekker, Griffith University, Australia,
Human Error Percentage
Richard Cook, University of Chicago, USA, Leila Johannesen, IBM Silicon Valley Lab, USA and Nadine Sarter, University of Michigan, USASeptember 2010 234 x 156 mm292 pages Hardback978-0-7546-7833-5 £65.00Human error is cited over and https://www.amazon.com/Behind-Human-Error-David-Woods/dp/0754678342 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 https://www.researchgate.net/publication/50387403_Behind_Human_Error 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 const
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human error is the stopping point for an investigation and ends the learning process. However, just as recent celebrated accidents in medicine have directed attention to patient safety, previous highly visible accidents in other industries, such as power generation and transportation drew attention to issues surrounding the label "human error" (e.g., Three Mile Island in 1979; the capsizing of the Herald of Free Enterprise in 1982; various aircraft accidents). The intense interest in these accidents led to sustained, cross-disciplinary studies of the human contribution to safety and accidents. To make sense of these accidents, as well as other less celebrated cases, researchers found a second, multi-faceted story hidden behind the label of human error that revealed patterns about how systems fail. Going behind the label human error points the way to effective learning and system improvements. In other words, the label human error should be seen as starting point for investigation. The result of research that pursues the "second" story has been a "new look" at the human contribution to safety and to failure. multiple contributors Traditionally, error analysis has focused on identifying the cause. However, one basic finding from "new look" research is that accidents in complex systems only occur through the concatenation of multiple small factors or failures, each necessary but only jointly sufficient to produce the accident. Often these small failures or vulnerabilities are present in the organization long before a specific incident is triggered. All complex systems contain such "latent" factors or failures, but only rarely do they combine to create the trajectory for an accident. It is useful to depict complex systems such as health care, aviation and electrical power generation as having a sharp and a blunt end. At the sharp end, practitioners interact with the hazardous process in their roles as pilots, spacecraft controllers, and, in medicine, as nurses, physicians, technicians, pharmacists and others. At the blunt end of the health care system are regulators, administrators, economic policy makers, and technology suppliers. The blunt end of the system controls the resources and constraints that confront the practitioner at the sharp end, shaping and presenting sometimes conflicting incentives and demands. "swiss cheese effect" creating safety Traditionally, accident analysis has focused on individuals as unreliable components. The searc