Introduction to Safety Science People, Organisations, and Systems

Preface Acknowledgements 1. Introduction to Safety 1.1The Toll of Toil 1.2 Workplace Safety Around the World 1.3 Relative Burdens of Workplace Illness and Injury 1.4 Does ‘Regulated Self-Regulation’ Work? 1.5 Transportation Safety 1.6 The ‘Safety Journey’ Section One: Individuals 2. Risk Perceiving Risk 2.1 Risk Tolerance 2.2 Risk-Taking and Accidents 2.3 Adapting to Risk 2.4 Quantifying Risk 2.5 Managing Risk 2.6 Safety Management Systems 2.7 Conclusions 3. Human Error The Varieties of Human Error 3.1 Coming Together: Academic Consensus on Human Error 3.2 Freudian Slips 3.3 Remembering to Remember 3.4 Error and Skill in Context 3.5 Error as an Industrial Safety Problem 3.6 The ‘Swiss Cheese’ Metaphor 3.7 Human Error Analysis in Practice 3.8 Summary and Conclusions 4. Safety by Design Designing for Flight Safety 4.1 Controls and Displays 4.2 Design for Action 4.3 Designing Tasks for Human Abilities 4.4 Attention and Performance 4.5 Decisions, Decisions 4.6 Light, Heat, and Reach 4.7 Summary and Conclusions Section Two: Organizations 5. Normal Accidents People in Context: Societies and Organizations 5.1 Normal Accident Theory 5.2 Error-Inducing Systems 5.3 The Management Paradox 5.4 The Dynamics of Normal Accidents 5.5 Assessing Normal Accident Theory 6. High Reliability Organizations 6.1 Commercial Aviation and the Mid-Air Collision 6.2 The Berkeley Project 6.3 Defining a ‘High Reliability Organization’ 6.4 Can we Rely on Healthcare? 6.5 The Contribution of HRO Theory 7. Normalization of Deviance, 7.1 Social Influence, 7.2 The Launch Decision, 7.3 Normalization of Deviance, 7.4 Safety Oversight at NASA, 7.5 Nothing Fails Like Success, 7.6 Applications of the ‘Normalization of Deviance’ Concept, 7.7 Drift into Failure Section Three: Systems 8. Cognitive Engineering: Constraints and Boundaries Constraints 8.1 The Decision Ladder 8.2 The Abstraction Hierarchy 8.3 Ecological Interface Design 8.4 The Boundaries of Safe Work 8.5 Mad Cows and Englishmen 8.6 ‘Workarounds’ in Healthcare 8.7 Summary and Conclusions 9. The Cybernetics of Safety: Information and Control 9.1 Feedback and Control 9.2 Information: The Difference That Makes a Difference 9.3 The STAMP Model of System Safety 9.4 Management Cybernetics: The Viable   Systems Model 9.5 Conclusions 10. Variability and Resilience Resilience Engineering 10.1 Resilient Healthcare 10.2 Resilience in Action 10.3 Safety-II 10.4 Safety Management: The New Agenda 10.5 Safety-II in Practice 10.6 Critique of Safety-II 10.7 Safety as a Systems Science 10.8 Conclusions 11. Making Sense of Failure: Beyond Accident Investigation (With Karl Bridges) 11.1 Accident Investigation 11.2 The Herald of Free Enterprise Disaster 11.3 Human Factors Analysis & Classification  System (HFACS) Accimap 11.4 Functional Resonance Analysis Method (FRAM) 11.5 Causal Analysis and Modelling Based on STAMP (CAST) 11.6 Comparisons Between the Accident Analysis Models 11.7 Systems Thinking in Accident Analysis 11.8 Conclusions Chapter Notes Index

Biography

David O’Hare is Professor of Psychology at the University of Otago. He joined the department in 1982 after graduating with a First Class Honours degree in psychology (1974) and a PhD (1978) from the University of Exeter followed by a several years lecturing at Lancaster University in the UK. At the same time he became a glider pilot and also obtained a UK Private Pilots Licence becoming increasingly interested in the human-machine relationship involved in aviation. He received a Prince and Princess of Wales award in 1987 and undertook a course in aircraft accident investigation at Cranfield University. After coming to NZ he started researching aeronautical decision making and spent time as a visiting scholar at The Ohio State University. Subsequently he and Professor Stan Roscoe wrote a book (‘Flightdeck Performance: The Human Factor’, published 1990) summarising the scientific literature on human perception and performance in aviation. In the ensuing years he has conducted research on a range of issues involving human interaction with technology, aviation safety, aircraft accidents, and pilot decision making with sponsors including the Health Research Council, NZ Civil Aviation Authority, the US Federal Aviation Administration and NASA. He edited the book: “Human Performance in General Aviation” published by Ashgate in 1999. He was a founder member of the NZ Human Factors and Ergonomics Society and established courses in Human Factors, Cognitive Engineering and Safety Science at the University of Otago. He is on the Editorial Board of the International Journal of Aerospace Psychology; the International Journal of Human Factors and Ergonomics and the Journal of Safety Research.