Investigating Human Error : Incidents, Accidents, and Complex Systems, Second Edition book cover
2nd Edition

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

ISBN 9781472458681
Published March 1, 2017 by CRC Press
343 Pages

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USD $62.95

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Book Description

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.

Table of Contents


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


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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"