Managing maintenance error: a practical guide
Saved in:
| Main Author: | |
|---|---|
| Format: | Book |
| Language: | English |
| Published: |
Aldershot [u.a.]
Ashgate
2003
|
| Subjects: | |
| Online Access: | Inhaltsverzeichnis |
| Physical Description: | XIV, 183 S. Ill. |
| ISBN: | 0754615901 075461591X |
Staff View
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| 245 | 1 | 0 | |a Managing maintenance error |b a practical guide |c James Reason ; Alan Hobbs |
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Record in the Search Index
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|---|---|
| adam_text | Contents
List of Figures ix
List of Tables xi
Preface xiii
1 Human Performance Problems in Maintenance 1
The bad news 1
The good news 3
Removal versus replacement 4
Commission versus omission errors 6
Summary 7
2 The Human Risks 9
Taking a systems view 9
Systems with human elements 10
Human related disturbances 11
Each disturbance has a history 12
Systems build defences against foreseeable disturbances 12
System defences can also fail 14
The moral issue 14
Errors are like mosquitoes 16
Looking ahead 17
3 The Fundamentals of Human Performance 19
Psychology meets engineering 19
A blueprint of mental functioning 20
Limitations of the conscious workspace 21
Attention 22
The vigilance decrement 24
Attention and habit 24
Control modes and situations 25
Three performance levels 27
v
vi Managing Maintenance Error
Stages in acquiring a skill 30
Fatigue 31
Stressors 32
Arousal 33
Coping with informational overload 33
Personality types 34
Biases in thinking and decision making 35
Summary 36
4 The Varieties of Error 39
What is an error? 39
Skill based recognition failures, slips and lapses 40
Rule based mistakes 49
Knowledge based errors 51
Violations 53
Violation types 55
The consequences of maintenance errors 59
Summary 60
5 Local Error provoking Factors 63
Documentation 64
Time pressure 65
Housekeeping and tool control 65
Coordination and communication 66
Tools and equipment 67
Fatigue 68
Knowledge and experience 70
Bad procedures 70
Procedure usage 72
Personal beliefs: a factor promoting violations 73
Links between errors and error provoking conditions 74
Summary 75
6 Three System Failures and a Model of Organizational
Accidents 77
Latent conditions and active failures 77
The Embraer 120 crash: a shift turnover failure 78
The Clapham Junction rail collision: the defences that
faded away 82
The Piper Alpha explosion: Failures of both the permit to
work and the shift handover systems 86
Modelling organizational accidents 89
Contents vii
Defences 91
Summary 93
7 Principles of Error Management 95
Nothing new 95
The principles of error management 96
The management of error management 100
Summarizing the EM principles 101
8 Person and Team Measures 103
Person measures 103
Team measures 113
Summary 117
9 Workplace and Task Measures 119
Fatigue management 119
Task frequency 120
Design 122
Housekeeping 124
Spares, tools and equipment 124
Using procedures to manage omissions 125
Summary 132
10 Organizational Measures 133
How accidents happen: a reminder 133
Reactive and proactive measures: working together 134
Reactive outcome measures 135
Proactive process measures 138
Identifying gaps in the defences 141
Summary 143
11 Safety Culture 145
What is a safety culture? 145
Can a safer culture be engineered? 147
Creating a just culture 148
Creating a reporting culture 151
Creating a learning culture 153
Types of safety culture: the good, the bad and the
average 155
Summary 156
viii Managing Maintenance Error
12 Making it Happen: The Management of Error
Management 159
Here comes another one 159
The common features of safety and quality management
systems 162
Why error management is necessary 164
More on mindset 165
In search of resilience 166
Summary 174
Index 177
List of Figures
1.1 The frequency of reoccurence of aircraft maintenance
incidents 4
2.1 A system with human elements 10
2.2 A symbolic representation of a human related
disturbance 11
2.3 Factors involved in the occurrence of human related
disturbances 12
2.4 A many layered defensive arrangement intervenes
between the disturbance and the vulnerable parts of
the system 13
2.5 Defences are never perfect: each one has holes and
gaps 14
3.1 A simplified blueprint of mental functioning 20
3.2 The torch beam model of human attention 23
3.3 A continuum of action control 26
3.4 Classifying situations along a continuum 27
3.5 Using the activity space to define the three performance
levels 29
3.6 The principal stages in skill acquisition 30
3.7 Time of day effects and fatigue 31
3.8 The relationship between arousal and the quality of
performance 33
3.9 Four personality types based upon the introversion
extraversion and stable unstable dimensions 35
4.1 The typical pattern of events involved in an action slip 47
4.2 Aircraft maintenance personnel questioned on whether
they have continued with an unfamiliar job despite
being uncertain how to proceed 53
4.3 The job of the shunter: linking up railway wagons 57
4.4 Comparison of error types resulting in quality incidents
and worker safety incidents 59
5.1 Maintenance errors in the context of local error
producing factors 63
5.2 Links between errors and contributing factors 74
6.1 The T tail assembly on an Embraer 120 79
ix
x Managing Maintenance Error
6.2 The locations of track relay DN and track repeater relay
DM in the relay room 83
6.3 Relay TRR DM showing the redundant wire connected
at the fuse end 84
6.4 Basic outline of the condensate injection pumps and
their connections 86
6.5 A summary of the stages involved in an organizational
accident 90
8.1 Comparing accidents per 10 000 km for control and
discussion groups pre test and post test 108
8.2 The ratio of behavioural changes to the underlying
mental changes 110
8.3 Primed schemata (knowledge structures) located
within a mental model of the task 112
9.1 Relative work related fatigue predictions for a five on
(06.00 to 14.00 hrs), two off, five on (14.00 to 22.00 hrs),
two off, five on (22.00 to 06.00 hrs), two off cyclic roster 121
9.2 The gulfs of execution and evaluation between the
user s model of what is going on and the actual state of
the system 123
10.1 Distinguishing between random and systematic error
patterns 136
10.2 A local factor profile 140
11.1 The main sub components of a safe culture 146
11.2 Distinguishing between single loop and double loop
organizational learning 153
Figure 6.1 with kind permission of Photovault.
Figures 6.2 and 6.3 with kind permission of British Transport Police.
List of Tables
1.1 The relationships between activities and performance
problems in nuclear power plant events 1
3.1 Contrasting the properties of the conscious workspace
and long term memory 22
3.2 The principal characteristics of the skill based, rule
based and knowledge based levels of performance 28
5.1 The mental balance sheet determining whether or not
a person will violate in a particular situation 71
5.2 Procedure usage in a petrochemical plant 72
9.1 Task Step Checklist 127
9.2 Ten criteria for a good reminder 131
10.1 How reactive outcome measures and proactive process
measures can work together to reveal systemic and
defensive weaknesses 135
12.1 Checklist for Assessing Institutional Resilience (CAIR) 171
xi
|
| any_adam_object | 1 |
| author | Reason, James T. 1938- |
| author_GND | (DE-588)128600535 |
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| dewey-search | 658.2/02 |
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| discipline | Maschinenbau / Maschinenwesen Psychologie Wirtschaftswissenschaften |
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| isbn | 0754615901 075461591X |
| language | English |
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| spelling | Reason, James T. 1938- Verfasser (DE-588)128600535 aut Managing maintenance error a practical guide James Reason ; Alan Hobbs Aldershot [u.a.] Ashgate 2003 XIV, 183 S. Ill. txt rdacontent n rdamedia nc rdacarrier Bedrijfsongevallen gtt Bedrijfsveiligheid gtt Fouten gtt Human engineering Industrial equipment Maintenance and repair Plant maintenance Industrieanlage (DE-588)4026801-9 gnd rswk-swf Fehlleistung (DE-588)4016619-3 gnd rswk-swf Instandhaltung (DE-588)4027145-6 gnd rswk-swf Menschliches Versagen (DE-588)4126524-5 gnd rswk-swf Industrieanlage (DE-588)4026801-9 s Instandhaltung (DE-588)4027145-6 s Menschliches Versagen (DE-588)4126524-5 s DE-604 Fehlleistung (DE-588)4016619-3 s Hobbs, Alan Sonstige oth HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=009878384&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Reason, James T. 1938- Managing maintenance error a practical guide Bedrijfsongevallen gtt Bedrijfsveiligheid gtt Fouten gtt Human engineering Industrial equipment Maintenance and repair Plant maintenance Industrieanlage (DE-588)4026801-9 gnd Fehlleistung (DE-588)4016619-3 gnd Instandhaltung (DE-588)4027145-6 gnd Menschliches Versagen (DE-588)4126524-5 gnd |
| subject_GND | (DE-588)4026801-9 (DE-588)4016619-3 (DE-588)4027145-6 (DE-588)4126524-5 |
| title | Managing maintenance error a practical guide |
| title_auth | Managing maintenance error a practical guide |
| title_exact_search | Managing maintenance error a practical guide |
| title_full | Managing maintenance error a practical guide James Reason ; Alan Hobbs |
| title_fullStr | Managing maintenance error a practical guide James Reason ; Alan Hobbs |
| title_full_unstemmed | Managing maintenance error a practical guide James Reason ; Alan Hobbs |
| title_short | Managing maintenance error |
| title_sort | managing maintenance error a practical guide |
| title_sub | a practical guide |
| topic | Bedrijfsongevallen gtt Bedrijfsveiligheid gtt Fouten gtt Human engineering Industrial equipment Maintenance and repair Plant maintenance Industrieanlage (DE-588)4026801-9 gnd Fehlleistung (DE-588)4016619-3 gnd Instandhaltung (DE-588)4027145-6 gnd Menschliches Versagen (DE-588)4126524-5 gnd |
| topic_facet | Bedrijfsongevallen Bedrijfsveiligheid Fouten Human engineering Industrial equipment Maintenance and repair Plant maintenance Industrieanlage Fehlleistung Instandhaltung Menschliches Versagen |
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