Organizational Accidents Revisited

Author: James Reason

Publisher: CRC Press

ISBN: 1134806078

Category: Technology & Engineering

Page: 160

View: 875

Managing the Risks of Organizational Accidents introduced the notion of an ’organizational accident’. These are rare but often calamitous events that occur in complex technological systems operating in hazardous circumstances. They stand in sharp contrast to ’individual accidents’ whose damaging consequences are limited to relatively few people or assets. Although they share some common causal factors, they mostly have quite different causal pathways. The frequency of individual accidents - usually lost-time injuries - does not predict the likelihood of an organizational accident. The book also elaborated upon the widely-cited Swiss Cheese Model. Organizational Accidents Revisited extends and develops these ideas using a standardized causal analysis of some 10 organizational accidents that have occurred in a variety of domains in the nearly 20 years that have passed since the original was published. These analyses provide the ’raw data’ for the process of drilling down into the underlying causal pathways. Many contributing latent conditions recur in a variety of domains. A number of these - organizational issues, design, procedures and so on - are examined in close detail in order to identify likely problems before they combine to penetrate the defences-in-depth. Where the 1997 book focused largely upon the systemic factors underlying organizational accidents, this complementary follow-up goes beyond this to examine what can be done to improve the ’error wisdom’ and risk awareness of those on the spot; they are often the last line of defence and so have the power to halt the accident trajectory before it can cause damage. The book concludes by advocating that system safety should require the integration of systemic factors (collective mindfulness) with individual mental skills (personal mindfulness).

Managing the Risks of Organizational Accidents

Author: James Reason

Publisher: Routledge

ISBN: 1134855354

Category: Technology & Engineering

Page: 272

View: 1770

Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.

A Life in Error

From Little Slips to Big Disasters

Author: Professor James Reason

Publisher: Ashgate Publishing, Ltd.

ISBN: 1472418417

Category: Political Science

Page: 150

View: 2367

This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. He presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. A Life in Error charts the development of his seminal and hugely influential work from its original focus on individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues.

Human Error

Author: James Reason

Publisher: Cambridge University Press

ISBN: 9780521314190

Category: Psychology

Page: 302

View: 2998

This 1991 book is a major theoretical integration of several previously isolated literatures looking at human error in major accidents.

The Human Contribution

Unsafe Acts, Accidents and Heroic Recoveries

Author: James Reason

Publisher: CRC Press

ISBN: 1351888110

Category: Technology & Engineering

Page: 310

View: 4772

This book explores the human contribution to the reliability and resilience of complex, well-defended systems. Usually the human is considered a hazard - a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns. However there is another perspective that has been relatively little studied in its own right - the human as hero, whose adaptations and compensations bring troubled systems back from the brink of disaster time and again. What, if anything, did these situations have in common? Can these human abilities be ’bottled’ and passed on to others? The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author’s focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.

Managing Maintenance Error

A Practical Guide

Author: James Reason,Alan Hobbs

Publisher: CRC Press

ISBN: 1351920510

Category: Technology & Engineering

Page: 200

View: 2734

Situations and systems are easier to change than the human condition - particularly when people are well-trained and well-motivated, as they usually are in maintenance organisations. This is a down-to-earth practitioner’s guide to managing maintenance error, written in Dr. Reason’s highly readable style. It deals with human risks generally and the special human performance problems arising in maintenance, as well as providing an engineer’s guide for their understanding and the solution. After reviewing the types of error and violation and the conditions that provoke them, the author sets out the broader picture, illustrated by examples of three system failures. Central to the book is a comprehensive review of error management, followed by chapters on:- managing person, the task and the team; - the workplace and the organization; - creating a safe culture; It is then rounded off and brought together, in such a way as to be readily applicable for those who can make it work, to achieve a greater and more consistent level of safety in maintenance activities. The readership will include maintenance engineering staff and safety officers and all those in responsible roles in critical and systems-reliant environments, including transportation, nuclear and conventional power, extractive and other chemical processing and manufacturing industries and medicine.

Just Culture

Balancing Safety and Accountability

Author: Sidney Dekker

Publisher: Ashgate Publishing, Ltd.

ISBN: 1409440605

Category: Technology & Engineering

Page: 171

View: 5480

While many organizations see the value of creating a just culture they struggle when it comes to developing it. In this Second Edition, Dekker expands his views, additionally tackling the key issue of how justice is created inside organizations. Dekker also introduces new material on ethics and on caring for the' second victim' (the professional at the centre of the incident). Consequently, we have a natural evolution of the author's ideas.

Barriers and Accident Prevention

Author: Erik Hollnagel

Publisher: Routledge

ISBN: 1351955934

Category: Transportation

Page: 242

View: 3898

Accidents are preventable, but only if they are correctly described and understood. Since the mid-1980s accidents have come to be seen as the consequence of complex interactions rather than simple threads of causes and effects. Yet progress in accident models has not been matched by advances in methods. The author's work in several fields (aviation, power production, traffic safety, healthcare) made it clear that there is a practical need for constructive methods and this book presents the experiences and the state-of-the-art. The focus of the book is on accident prevention rather than accident analysis and unlike other books, has a proactive rather than reactive approach. The emphasis on design rather than analysis is a trend also found in other fields. Features of the book include: -A classification of barrier functions and barrier systems that will enable the reader to appreciate the diversity of barriers and to make informed decisions for system changes. -A perspective on how the understanding of accidents (the accident model) largely determines how the analysis is done and what can be achieved. The book critically assesses three types of accident models (sequential, epidemiological, systemic) and compares their strengths and weaknesses. -A specific accident model that captures the full complexity of systemic accidents. One consequence is that accidents can be prevented through a combination of performance monitoring and barrier functions, rather than through the elimination or encapsulation of causes. -A clearly described methodology for barrier analysis and accident prevention. Written in an accessible style, Barriers and Accident Prevention is designed to provide a stimulating and practical guide for industry professionals familiar with the general ideas of accidents and human error. The book is directed at those involved with accident analysis and system safety, such as managers of safety departments, risk and safety consultants, human factors professionals, and accident investigators. It is applicable to all major application areas such as aviation, ground transportation, maritime, process industries, healthcare and hospitals, communication systems, and service providers.

FRAM: The Functional Resonance Analysis Method

Modelling Complex Socio-technical Systems

Author: Erik Hollnagel

Publisher: CRC Press

ISBN: 135193595X

Category: Technology & Engineering

Page: 160

View: 2331

Resilience engineering has consistently argued that safety is more than the absence of failures. Since the first book was published in 2006, several book chapters and papers have demonstrated the advantage in going behind 'human error' and beyond the failure concept, just as a number of serious accidents have accentuated the need for it. But there has not yet been a comprehensive method for doing so; the Functional Resonance Analysis Method (FRAM) fulfils that need. Whereas commonly used methods explain events by interpreting them in terms of an already existing model, the FRAM is used to model the functions that are needed for everyday performance to succeed. This model can then be used to explain specific events, by showing how functions can be coupled and how the variability of everyday performance sometimes may lead to unexpected and out-of-scale outcomes - either good or bad. The FRAM is based on four principles: equivalence of failures and successes, approximate adjustments, emergence, and functional resonance. As the FRAM is a method rather than a model, it makes no assumptions about how the system under investigation is structured or organised, nor about possible causes and cause-effect relations. Instead of looking for failures and malfunctions, the FRAM explains outcomes in terms of how functions become coupled and how everyday performance variability may resonate. This book presents a detailed and tested method that can be used to model how complex and dynamic socio-technical systems work, to understand why things sometimes go wrong but also why they normally succeed.

NASA Formal Methods

10th International Symposium, NFM 2018, Newport News, VA, USA, April 17-19, 2018, Proceedings

Author: Aaron Dutle,César Muñoz,Anthony Narkawicz

Publisher: Springer

ISBN: 3319779354

Category: Computers

Page: 470

View: 1038

This book constitutes the proceedings of the 10th International Symposium on NASA Formal Methods, NFM 2018, held in Newport News, VA, USA, in April 2018. The 24 full and 7 short papers presented in this volume were carefully reviewed and selected from 92 submissions. The papers focus on formal techniques and other approaches for software assurance, their theory, current capabilities and limitations, as well as their potential application to aerospace, robotics, and other NASA-relevant safety-critical systems during all stages of the software life-cycle.

Predicting User Performance and Errors

Automated Usability Evaluation Through Computational Introspection of Model-Based User Interfaces

Author: Marc Halbrügge

Publisher: Springer

ISBN: 3319603698

Category: Computers

Page: 149

View: 6613

This book proposes a combination of cognitive modeling with model-based user interface development to tackle the problem of maintaining the usability of applications that target several device types at once (e.g., desktop PC, smart phone, smart TV). Model-based applications provide interesting meta-information about the elements of the user interface (UI) that are accessible through computational introspection. Cognitive user models can capitalize on this meta-information to provide improved predictions of the interaction behavior of future human users of applications under development. In order to achieve this, cognitive processes that link UI properties to usability aspects like effectiveness (user error) and efficiency (task completion time) are established empirically, are explained through cognitive modeling, and are validated in the course of this treatise. In the case of user error, the book develops an extended model of sequential action control based on the Memory for Goals theory and it is confirmed in different behavioral domains and experimental paradigms. This new model of user cognition and behavior is implemented using the MeMo workbench and integrated with the model-based application framework MASP in order to provide automated usability predictions from early software development stages on. Finally, the validity of the resulting integrated system is confirmed by empirical data from a new application, eliciting unexpected behavioral patterns.

Brideshead Revisited

Author: Evelyn Waugh

Publisher: Little, Brown

ISBN: 0316216534

Category: Fiction

Page: 432

View: 9468

The wellsprings of desire and the impediments to love come brilliantly into focus in Evelyn Waugh's masterpiece-a novel that immerses us in the glittering and seductive world of English aristocracy in the waning days of the empire. Through the story of Charles Ryder's entanglement with the Flytes, a great Catholic family, Evelyn Waugh charts the passing of the privileged world he knew in his own youth and vividly recalls the sensuous pleasures denied him by wartime austerities. At once romantic, sensuous, comic, and somber, Brideshead Revisited transcends Waugh's early satiric explorations and reveals him to be an elegiac, lyrical novelist of the utmost feeling and lucidity.

The Natural History of Alcoholism Revisited

Author: George E. VAILLANT

Publisher: Harvard University Press

ISBN: 0674044568

Category: Psychology

Page: 462

View: 5062

In this updated version of his landmark study on alcoholism, George Vaillant returns to the same subjects, but with the perspective gained from fifteen years of further follow-up.

The Downing of TWA Flight 800

Author: James Sanders

Publisher: Pinnacle Books

ISBN: 0786034955

Category: Social Science

Page: 320

View: 6493

NOT THEORY—FACT! A MISSLE SHOT DOWN FLIGHT 800! On July 17, 1996, minutes after take-off, TWA Flight 800 was blown out of the sky, killing all 230 people on board. What happened? It took federal investigators nearly a year and millions of tax dollars to point to a fuel tank explosion. But the investigation was riddled with questionable procedures. Was the government hiding a huge military embarrassment? Was the plane shot down by a missile? The Indisputable Evidence. . . Reddish residue from missile fuel on passenger seats Clean entry and exit hole in forward cabin 34 certified eyewitnesses to airborne projectile not allowed to testify FAA radar tapes or projectile in path with Flight 800 Government documents confirm Naval testing in area that night And more! Who launched the missile? How much did the government know and when? Was it simple bureaucratic incompetence or the most massive cover-up in U.S. history? Ex-cop turned acclaimed investigative reporter Jim Sanders exposed the shocking truth in 1997. Despite unremitting threats to his life, he has recovered even more evidence the FBI tried to suppress about the true history of TWA Flight 800. Include explosive photos!

Safety at the Sharp End

A Guide to Non-Technical Skills

Author: Rhona Flin,Paul O'Connor

Publisher: CRC Press

ISBN: 1317059948

Category: Technology & Engineering

Page: 330

View: 9508

Many 21st century operations are characterised by teams of workers dealing with significant risks and complex technology, in competitive, commercially-driven environments. Informed managers in such sectors have realised the necessity of understanding the human dimension to their operations if they hope to improve production and safety performance. While organisational safety culture is a key determinant of workplace safety, it is also essential to focus on the non-technical skills of the system operators based at the 'sharp end' of the organisation. These skills are the cognitive and social skills required for efficient and safe operations, often termed Crew Resource Management (CRM) skills. In industries such as civil aviation, it has long been appreciated that the majority of accidents could have been prevented if better non-technical skills had been demonstrated by personnel operating and maintaining the system. As a result, the aviation industry has pioneered the development of CRM training. Many other organisations are now introducing non-technical skills training, most notably within the healthcare sector. Safety at the Sharp End is a general guide to the theory and practice of non-technical skills for safety. It covers the identification, training and evaluation of non-technical skills and has been written for use by individuals who are studying or training these skills on CRM and other safety or human factors courses. The material is also suitable for undergraduate and post-experience students studying human factors or industrial safety programmes.

The Island of the Colorblind

Author: Oliver Sacks

Publisher: Vintage

ISBN: 0345805895

Category: Psychology

Page: 336

View: 4342

Oliver Sacks has always been fascinated by islands--their remoteness, their mystery, above all the unique forms of life they harbor. For him, islands conjure up equally the romance of Melville and Stevenson, the adventure of Magellan and Cook, and the scientific wonder of Darwin and Wallace. Drawn to the tiny Pacific atoll of Pingelap by intriguing reports of an isolated community of islanders born totally color-blind, Sacks finds himself setting up a clinic in a one-room island dispensary, where he listens to these achromatopic islanders describe their colorless world in rich terms of pattern and tone, luminance and shadow. And on Guam, where he goes to investigate the puzzling neurodegenerative paralysis endemic there for a century, he becomes, for a brief time, an island neurologist, making house calls with his colleague John Steele, amid crowing cockerels, cycad jungles, and the remains of a colonial culture. The islands reawaken Sacks's lifelong passion for botany--in particular, for the primitive cycad trees, whose existence dates back to the Paleozoic--and the cycads are the starting point for an intensely personal reflection on the meaning of islands, the dissemination of species, the genesis of disease, and the nature of deep geologic time. Out of an unexpected journey, Sacks has woven an unforgettable narrative which immerses us in the romance of island life, and shares his own compelling vision of the complexities of being human. From the Hardcover edition.

On the Practice of Safety

Author: Fred A. Manuele

Publisher: John Wiley & Sons

ISBN: 1118574761

Category: Technology & Engineering

Page: 616

View: 7112

Explains how to implement the best safety practices and why they work Reviews from the Third Edition "An excellent piece of work." —Safety Health Practitioner (SHP) "This is a book to be read now for its educational value and also to be kept on the shelf for easy future reference." —Chemistry International "A useful fountain of knowledge." —Quality World The Fourth Edition of On the Practice of Safety makes it possible for readers to master all the core subjects and practices that today's safety professionals need to know in order to provide optimal protection for their organizations' property and personnel. Like the previous editions, each chapter is a self-contained unit, making it easy for readers to focus on select topics of interest. Thoroughly revised and updated, this Fourth Edition reflects the latest research and safety practice standards. For example, author Fred Manuele has revised the design chapters to reflect the recently adopted American National Standard on Prevention through Design. In addition, readers will find new chapters dedicated to: Management of change and pre-job planning Indirect-to-direct accident cost ratios Leading and lagging indicators Opportunities for safety professionals to apply lean concepts Role of safety professionals in implementing sustainability Financial management concepts and practices that safety professionals should know Many chapters are highly thought-provoking, questioning long-accepted concepts in the interest of advancing and improving the professional practice of safety. Acclaimed by both students and instructors, On the Practice of Safety is a core textbook for both undergraduate and graduate degree programs in safety. Safety professionals should also refer to the text in order to update and improve their safety skills and knowledge.

Electrical Safety and the Law

Author: John M Madden

Publisher: Taylor & Francis

ISBN: 131720851X

Category: Technology & Engineering

Page: 388

View: 6339

Electrical Safety and the Law describes the hazards and risks from the use of electricity, explaining with the help of case studies and accident statistics the types of accidents that occur and how they can be prevented by the use of safe installations, equipment and working practices. It describes the British legislation on the safety of electrical systems and electrotechnical machinery control systems, much of which stems from European Directives and which will therefore be affected by the UK’s decision to leave the EU (Brexit), and the main standards and guidance that can be used to secure compliance with the law. There are detailed descriptions covering the risks and preventive measures associated with electrical installations, construction sites, work near underground cables and overhead power lines, electrical equipment and installations in explosive atmospheres, electrical testing and electrotechnical control systems. Duty holders’ responsibilities for designing, installing, and maintaining safe systems are explained, as well as their responsibilities for employing competent staff. The fifth edition has been substantially updated to take account of considerable changes to the law, standards and guidance; it has been expanded to include: a new chapter on the Corporate Manslaughter and Corporate Homicide Act; a new chapter describing landlords’ legal responsibilities for electrical safety in private rented properties and social housing; a new chapter on the Electricity Safety Quality and Continuity Regulations; new information on offences, penalties, sentencing guidelines, and relevant case law; a description of the main requirements of BS 7671:2008 and other principal standards, many of which have been amended in recent years; new cases studies to illustrate the hazards and risks; information on changes to GB’s health and safety system.

Friendly Fire

The Accidental Shootdown of U.S. Black Hawks over Northern Iraq

Author: Scott A. Snook

Publisher: Princeton University Press

ISBN: 140084097X

Category: Social Science

Page: 280

View: 3349

On April 14, 1994, two U.S. Air Force F-15 fighters accidentally shot down two U.S. Army Black Hawk Helicopters over Northern Iraq, killing all twenty-six peacekeepers onboard. In response to this disaster the complete array of military and civilian investigative and judicial procedures ran their course. After almost two years of investigation with virtually unlimited resources, no culprit emerged, no bad guy showed himself, no smoking gun was found. This book attempts to make sense of this tragedy--a tragedy that on its surface makes no sense at all. With almost twenty years in uniform and a Ph.D. in organizational behavior, Lieutenant Colonel Snook writes from a unique perspective. A victim of friendly fire himself, he develops individual, group, organizational, and cross-level accounts of the accident and applies a rigorous analysis based on behavioral science theory to account for critical links in the causal chain of events. By explaining separate pieces of the puzzle, and analyzing each at a different level, the author removes much of the mystery surrounding the shootdown. Based on a grounded theory analysis, Snook offers a dynamic, cross-level mechanism he calls "practical drift"--the slow, steady uncoupling of practice from written procedure--to complete his explanation. His conclusion is disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable organization.