2nd Edition

Investigating Human Error Incidents, Accidents, and Complex Systems, Second Edition

By Barry Strauch Copyright 2017
    343 Pages
    by CRC Press

    344 Pages
    by CRC Press

    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.


    Chapter One: Introduction

    Part I Errors and Complex Systems

    Chapter Two: Errors, Complex Systems, Accidents, and Investigations

    Chapter Three: Analyzing the Data

    Chapter Four: Equipment

    Part II: Antecedents

    Chapter Five: The Operator

    Chapter Six: The Company

    Chapter Seven: The regulator

    Chapter Eight: Culture

    Chapter Nine: Operator Teams

    Part III: Sources of Data

    Chapter Ten: Electronic Data

    Chapter Eleven: Interviews

    Chapter Twelve: Written Documentation

    Part IV: Issues

    Chapter Thirteen: Maintenance and Inspection

    Chapter Fourteen: Situation Awareness and Decision Making

    Chapter Fifteen: Automation

    Chapter Sixteen: Case Study

    Chapter Seventeen: Final Thoughts



    Barry Strauch has lectured and taught human factors, accident investigation techniques, and human error to accident investigators, graduate students, and government and industry officials throughout the world. He is an adjunct faculty member of the psychology department of George Mason University in Fairfax, Virginia. He has been with the National Transportation Safety Board for more than 30 years as a human performance investigator, major aircraft accident investigator in charge, chief of the human performance division and, currently, National Resource Specialist - Human Factors. He has investigated accidents in all major transportation modes, involving vehicles ranging from passenger trains, to Boeing 747s, to nuclear attack submarines. He earned a PhD in educational psychology from the Pennsylvania State University and holds a commercial pilot certificate, with an instrument aeroplane rating.

    "This is an extremely important book, one that literally can save lives. For decades, I've argued that blaming an accident was on "human error" is not helpful. It is necessary to understand the root causes (invariably plural) and fix those, otherwise the errors continue. Often the fault lies in design, either of the system or the procedures, but there are a multitude of potential underlying, causes. Barry Strauch's book discusses these issues and provides detailed, valuable guidelines for investigating incidents with the goal, not of finding blame, but of preventing future recurrence."
    Don Norman, University of California, San Diego Design Lab
    Author of "Design of Everyday Things"