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Dekker - The Field Guide to Understanding Human Error

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Dekker The Field Guide to Understanding Human Error
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When faced with a human error problem, you may be tempted to ask Why didnt these people watch out better? Or, How can I get my people more engaged in safety? You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of The Bad Apple Theory where you believe your system is basically safe if it were not for those few unreliable people in it. Building on its successful predecessors, the third edition of The Field Guide to Undiferstanding Human Error will help you undiferstand a new way of dealing with a perceived human error problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call human error, allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, undifer the pressure of resource constraints and multiple conflicting goals. The Field Guide to Undiferstanding Human Error will help you undiferstand how to move beyond human error; how to undiferstand accidents; how to do better investigations; how to undiferstand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a human error problem, abandon the fallacy of a quick fix. Read this book.--Provided by publisher.;Chapter 1 Two Views of {u2018}Human Error{u2019} -- chapter 2 Containing Your Reactions to Failure -- chapter 3 Doing a {u2018}Human Error{u2019} Investigation -- chapter 4 Explaining the Patterns of Breakdown -- chapter 5 Undiferstanding Your Accident Model -- chapter 6 Creating an Effective Safety Department -- chapter 7 Building a Safety Culture -- chapter 8 Abandoning the Fallacy of a Quick Fix.

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THE FIELD GUIDE TO UNDERSTANDING HUMAN ERROR Its in the worlds best interest - photo 1

THE FIELD GUIDE TO UNDERSTANDING HUMAN ERROR

Its in the worlds best interest to read Dekkers book. The Field Guide is nothing short of a paradigm shift in thinking about human error, and in my domain of software and Internet engineering, it should be considered required reading. This Third Edition is much better than the Second, and the layout of the material is far more accessible.

John Allspaw, SVP, Infrastructure and Operations, Etsy

If you design equipment or operating procedures, if you investigate accidents or deal with safety, this is an essential book. Sidney Dekker, a leading world authority on human error has enhanced his already exceptional Field Guide to be a concise, readable guide to both design of equipment and procedures and also the analysis of mishaps. The label human error is misleading and its use prevents discovery and correction of the true underlying causes of incidents. So read about hindsight bias, about the difference between the view from inside the system rather than from outside, and about difference between the blunt end (where you should do your work) and the sharp end (where people tend to focus). Read, learn, and put these ideas into practice. The results will be fewer incidents, less damage, less injury.

Don Norman, author of The Design of Everyday Things

The Third Edition of Sidney Dekkers Field Guide to Understanding Human Error provides a solid practical framework for anyone wanting to make sense of safety science, human factors analysis, and the New View approach to conducting investigations of incidents and accidents. The trademark direct and passionate style that is common in Dekkers work focuses on the circumstances of frontline operators and managers working in complex systems, as well as the challenges of the safety investigator. Dekker does not mince his words (Any human factors investigation that does not take goal conflicts seriously does not take human work seriously) and is clearly supportive both of sharp end workers, who are tasked with creating safety in the face of resource constraints in complex systems, as well as the investigators, charged with making sense of events that often seem surprising and unpredictable. Several new topics are introduced and enrich the earlier versions of The Field Guidefor instance the chapter on creating a safety department presents important principles for those with the courage to take on such a daunting task. This will be an invaluable resource for any organization serious about understanding and improving the safety of their operations.

Dr Robert Robson, Principal Advisor, Healthcare System Safety and Accountability, Inc.

When things go wrong in organisations, one thing is almost always found in the postmortem: human error (in various guises). But one only needs to scratch the surface of system failures to understand that things are not so straightforward. What seems to make sense as a causal catch-all for our everyday slips and blunders snaps when stretched; it fails to explain the context and complexity of our work and systems.

There is a better way. In this important book, Sidney Dekker conveys a practical approach for life after human error. It is both humanistic and systemic; it treats people holistically and non-judgementally, while considering system conditions and dynamics in context. If you are prepared to suspend your own preconceptions and reactions to failure this book will repay you with a practical, highly readable and deeply humane approach to dealing with failure.

Steven Shorrock, European Safety Culture Program Leader, EUROCONTROL

Comments on the Second edition:

Next time Im lecturing students, Ill be recommending The Field Guide as required reading! Well done.

Barry Kirwan, System Safety and Human Error, Eurocontrol, France; Co-editor of Changing Regulation: Controlling Risks in Society and Human Factors Impacts in Air Traffic Management

It is accessible, practical, eminently readable and will be of great use to safety practitioners whatever their background.

Health & Safety at Work, July 2007

This past year I read your book The Field Guide to Understanding Human Error based on a recommendation of a colleague. I must admit it is one of the best book that I have read on accident prevention and safety. I have been practicing as a construction safety professional for 17 years and have struggled to accurately and completely articulate the concepts you so eloquently describe in your book. Although it draws many examples from an aviation safety standpoint, your book stands up brilliantly as a framework for understanding human error and accident prevention in any industry. Subsequently, I am using it as the text for my course Safety in the Construction Industry here at Columbia this fall.

The construction industry is so very stuck in the world of the Old View. Convincing construction management professional that removing bad apples is not the answer is a tough sell. Your book is making my job quite a bit easier. Thank you.

Ray Master, Columbia University, USA

I have every executive in the entire Department of Energy reading The Field Guide as we speak.

Todd Conklin, Los Alamos National Laboratory

No matter if the reader is an upper level executive in an aerospace company, a member of an accident investigation team, a safety engineer, or a university student, Sidneys Field Guide is equally as useful. This book presents important ideas for those who regulate human factors investigation and research, making it an essential read for the academician, the research analyst, and the government regulator.

International Journal of Applied Aviation Studies, Vol. 7, No. 2

The Field Guide to Understanding Human Error

Third Edition

SIDNEY DEKKER

Griffith University, Australia

CRC Press Taylor Francis Group 6000 Broken Sound Parkway NW Suite 300 Boca - photo 2

CRC Press

Taylor & Francis Group

6000 Broken Sound Parkway NW, Suite 300

Boca Raton, FL 33487-2742

2014 by Sidney Dekker

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

Version Date: 20160513

International Standard Book Number-13: 978-1-4724-3904-8 (Hardback) 978-1-4724-3905-5 (Paperback)

This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers.

For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged.

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