1st Edition

Investigating Human Error: Incidents, Accidents, and Complex Systems

By Barry Strauch Copyright 2004
    324 Pages
    by Routledge

    by Routledge

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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. Features include: - an easy to follow step by step approach to conducting error investigations that even those new to the field can readily apply. - summaries of recent transportation accidents and human factors literature and relates them to the cause of human error in accidents. - an approach to investigating human error that will be of interest to both human factors psychology and industrial engineering students and instructors, as well as investigators of accidents in aviation, mass transportation, nuclear power, or any industry that is to the adverse effects of error. Based on the author's over 18 years of 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.

    Contents: Part I Errors and Complex Systems: Introduction; Errors, complex systems, accidents, and investigations. Part II Antecedents: Equipment; The operator; The company and the regulator; Maintenance and inspection; Multi-operator systems; Culture. Part III Data and Data Analysis: System recorders; Written documentation; Interviews; Analysis. Part IV Issues: Situation awareness and decision making; Automation. Part V Applying the Data: Case study; Final thoughts; References; Index.


    Barry Strauch has lectured and taught human factors, aircraft 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, an instructor at George Washington University's aviation management certificate program in Washington, DC, and serves on the editorial board of the International Journal of Aviation Psychology. He has been with the National Transportation Safety Board for over 18 years as a human performance investigator, major aircraft accident investigator in charge, chief of the human performance division, and currently, Assistant Director for Instruction of the NTSB Academy. 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.

    ’...essential reading for the professional investigator and the serious student of the subject. Strauch is commendably thorough. Do not be discouraged from buying the book because you do not work in aviation. In fact, reading about accidents in other industries we see the causes more clearly as we are not involved.' Industrial Safety Magazine 'It is always exciting to receive new books from Ashgate in the sure expectancy of new findings and fresh interpretation...as hard to put down as a crime detection thriller, with carefully researched case histories revealing disastrous sequences of human error, maladministration and criminal neglect far stranger than fiction. This is an important and valuable book...' The RoSPA Occupational Safety and Health Journal