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