The human contribution: unsafe acts, accidents, and heroic recoveries
Saved in:
| Main Author: | |
|---|---|
| Format: | Book |
| Language: | English |
| Published: |
Burlington, VT [u.a.]
Ashgate
2008
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| Subjects: | |
| Online Access: | Inhaltsverzeichnis |
| Item Description: | Includes index. |
| Physical Description: | X, 295 S. graph. Darst. |
| ISBN: | 9780754674009 9780754674023 |
Staff View
MARC
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| 245 | 1 | 0 | |a The human contribution |b unsafe acts, accidents, and heroic recoveries |c James Reason |
| 264 | 1 | |a Burlington, VT [u.a.] |b Ashgate |c 2008 | |
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| 500 | |a Includes index. | ||
| 650 | 4 | |a Errors | |
| 650 | 4 | |a System safety | |
| 650 | 4 | |a System safety | |
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Record in the Search Index
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|---|---|
| adam_text | Contents
List of Figures
List of Tables
About the Author
IX
xi
xiii
PART I INTRODUCTION 1
Chapter 1 The Human Contribution: Hazard and Hero 3
Introduction 3
The structure of the book 4
About the book 8
Chapter 2 A Mind User s Guide 9
Tip-of-the-tongue state 9
The conscious and automatic modes of control 10
Three levels of performance 13
Interacting with the long-term knowledge base 15
Intentions and the retrieval cycle 17
Concurrent processing 18
The relationship between memory and attention:
the blob-and-the-board model 20
Summing up 22
PART II UNSAFE ACTS 27
Chapter 3 The Nature and Varieties of Human Error 29
Defining and classifying error 29
Error myths 36
Slips and lapses 38
Rule-based mistakes 45
Knowledge-based mistakes 45
Conclusion: a general rule 46
vi The Human Contribution
Chapter 4 Violations and the Varieties of Rule-related
Behaviour 49
Chernobyl and Zeebrugge 49
Violations considered as unsafe acts 51
Who is most likely to violate? 55
Why do people violate safety rules? 55
The mental economics of violating 57
Bad procedures 58
Procedure-usage 58
Testing two models of violating behaviour 59
The varieties of rule-related behaviour 60
Great improvisers 66
End piece 66
Chapter 5 Perceptions of Unsafe Acts 69
The plague model 70
The person model 71
The legal model 90
The system perspective 92
Person and system models: getting the balance
right 102
PART III ACCIDENTS 105
Chapter 6 Error Traps and Recurrent Accidents 107
Accident proneness: a quick survey 107
Everyday error traps 111
Recurrent accident patterns 113
The elements of recurrent scenarios 124
Cultural drivers 126
Conclusion 127
Chapter 7 Significant Accident Investigations 129
Problems with the past 129
Changes in accident investigation 131
The Mahon and Moshansky reports 133
Has the pendulum swung too far? 136
Conditions and causes 137
Counterfactual fallacy * 137
The current view 138
Contents vii
PART IV HEROIC RECOVERIES 141
Chapter 8 Training, Discipline and Leadership 143
The Light Division s retreat at Fuentes de Onoro
(1811) 143
The withdrawal of the 1st Marine Division from
Chosin Reservoir (1950) 149
Concluding remarks 159
Chapter 9 Sheer Unadulterated Professionalism 161
Captain Rostron and the rescue of the Titanic
survivors (1912) 162
Saving Apollo 13 (1970) 169
British Airways Flight 09 (1982) 177
The BAC 1-11 incident (1990) 180
Surgical excellence (1995-97) 184
Minor and major events 185
Concluding remarks 193
Chapter 10 Skill and Luck 195
The Gimli Glider 195
Captain Al Haynes and United 232 200
Final word 207
Chapter 11 Inspired Improvisations 209
General Gallieni and the Paris taxis 209
Captain Gordon Vette and the rescue of Jay
Prochnow 213
Conclusion 218
Chapter 12 The Ingredients of Heroic Recovery 221
Coping with expected hazards 221
Coping with unlikely but possible hazards 223
Generic qualities 229
Conclusion 236
PART V ACHIEVING RESILIENCE 237
Chapter 13 Individual and Collective Mindfulness 239
Consistency versus variability 239
viii The Human Contribution
A dynamic non-event 239
Collective mindfulness 240
Individual mindfulness 243
Aspects of resilience 248
Foresight training at the UK National Patient
Safety Agency 250
Organisational support 251
Looking towards the future 253
Mindfulness and resilience 262
Chapter 14 In Search of Safety 265
Introduction 265
What does the term safety mean? 265
The two faces of safety 267
The safety space model 268
What does a resilient system look like? 276
The knotted rubber band model 280
Defining the nature of positive safety 284
Final words 287
Index 289
List of Figures
Figure 2.1 Three levels of performance control 13
Figure 2.2 The blob-and-the-board model 21
Figure 5.1 First version of the Swiss cheese model
(though it hadn t yet taken on its Emmenthale
appearance. Various human contributions to
the breakdown of complex systems are mapped
on to the basic elements of production 97
Figure 5.2 Part of the earliest version of the Swiss cheese
model. The diagram shows a trajectory of
accident opportunity penetrating several
defensive layers, and begins to have
Emmenthale-ish features 98
Figure 5.3 The early 90 s variant of the Swiss cheese model 99
Figure 5.4 A mid-90s variation with two interacting
pathways to an accident 100
Figure 5.5 The latest version of the Swiss cheese model 102
Figure 6.1 Showing the unequal liability to accidents in
a group exposed to the same hazards over
the same time period. The curve represents
the chance prediction of event likelihood
(Poisson distribution). The columns represent
the actual number of accide 108
Figure 6.2 Kanizsa Triangle 122
Figure 7.1 Tracing the shifting emphases of accident
investigations 131
Figure 8.1 The manoeuvres required in preparing to
receive cavalry on the march. 144
Figure 8.2 The Battle of Fuentess de Onoro, 5th May 1811 147
Figure 8.3 Showing the area over which the Chosin
Reservoir campaign was fought 151
x The Human Contribution
Figure 9.1 A cutaway diagram of the service module, It
was the round cryogenic oxygen tank (second
layer) that exploded and nearly destroyed
the spacecraft 171
Figure 9.2a Surgical defences in the arterial switch operation
represented as Swiss cheese slices in which the
holes do not line up 188
Figure 9.2b Using the Swiss cheese model to represent a
typical major event scenario 189
Figure 9.3a The slice of Cheddar at the left hand end
represents coping abilities 189
Figure 9.3b The mouse nibbling at the slice of Cheddar
represents how adverse events, both major
and minor, can eat away at limited coping
resources 190
Figure 11.1 Flying the aural box pattern into the VHF
range circle 216
Figure 13.1 Combining individual and collective
mindfulness to enhance patient safety 242
Figure 13.2 The three-bucket model for assessing high-risk
situations 246
Figure 13.3 How the bucket contents might be interpreted 247
Figure 13.4 Tracing the possible progress of developments
in patient safety 255
Figure 13.5 Showing the reduction in variability as the
cycle progresses 262
Figure 14.1 Illustrating vulnerability and resistance. The
arrows at the top of the figure represent
perturbing forces 268
Figure 14.2 Showing a number of hypothetical organisations
within the same hazardous domain distributed
throughout the safety space 269
Figure 14.3 Summarising the driving forces and navigational
aids necessary to propel an organisation towards
the region of maximum resistance 275
Figure 14.4 Three states of the knotted rubber band 280
Figure 14.5 Showing the resource implications of the
knotted rubber band model 283
List of Tables
Table 2.1 Comparing the properties of the conscious
workspace and the long-term knowledge
base 12
Table 3.1 Comparing the properties of exceedances,
incidents and accidents 36
Table 4.1 Summarising the violation balance sheet 58
Table 4.2 Summarising the 12 varieties of rule-related
behaviour 62
Table 5.1 Comparing the CANDU and RBMK safety
features 81
Table 7.1 Three examples of the distinction between
cause and condition 137
Table 14.1 Summarising the interactions between reactive
and proactive measures 272
Table 14.2 Combining the 3Cs and the 4Ps to produce 12
sets of indicators 276
|
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| illustrated | Illustrated |
| indexdate | 2024-07-09T21:30:20Z |
| institution | BVB |
| isbn | 9780754674009 9780754674023 |
| language | English |
| lccn | 2008038859 |
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| physical | X, 295 S. graph. Darst. |
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| spelling | Reason, James T. 1938- Verfasser (DE-588)128600535 aut The human contribution unsafe acts, accidents, and heroic recoveries James Reason Burlington, VT [u.a.] Ashgate 2008 X, 295 S. graph. Darst. txt rdacontent n rdamedia nc rdacarrier Includes index. Errors System safety Faktor Mensch (DE-588)4812463-1 gnd rswk-swf Faktor Mensch (DE-588)4812463-1 s b DE-604 HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=017086437&sequence=000004&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Reason, James T. 1938- The human contribution unsafe acts, accidents, and heroic recoveries Errors System safety Faktor Mensch (DE-588)4812463-1 gnd |
| subject_GND | (DE-588)4812463-1 |
| title | The human contribution unsafe acts, accidents, and heroic recoveries |
| title_auth | The human contribution unsafe acts, accidents, and heroic recoveries |
| title_exact_search | The human contribution unsafe acts, accidents, and heroic recoveries |
| title_full | The human contribution unsafe acts, accidents, and heroic recoveries James Reason |
| title_fullStr | The human contribution unsafe acts, accidents, and heroic recoveries James Reason |
| title_full_unstemmed | The human contribution unsafe acts, accidents, and heroic recoveries James Reason |
| title_short | The human contribution |
| title_sort | the human contribution unsafe acts accidents and heroic recoveries |
| title_sub | unsafe acts, accidents, and heroic recoveries |
| topic | Errors System safety Faktor Mensch (DE-588)4812463-1 gnd |
| topic_facet | Errors System safety Faktor Mensch |
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