Foundations of safety science: a century of understanding accidents and disasters
Gespeichert in:
| 1. Verfasser: | |
|---|---|
| Format: | Buch |
| Sprache: | English |
| Veröffentlicht: |
Boca Raton ; London ; New York
CRC Press
[2019]
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| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | Includes index |
| Beschreibung: | xxi, 445 Seiten Illustrationen |
| ISBN: | 9781138481787 9781138481770 |
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Datensatz im Suchindex
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| adam_text | Contents Preface...........................................................................................................................xiii Author........................................................................................................................... xxi Chapter 1 The 1900s and Onward: Beginnings...................................................... 1 Drew Rae and Sidney Dekker 1.1 1.2 1.3 1.4 1.5 Introduction....................................................................................1 Safety and Risk: Divine or Human?..............................................2 Modernity and Humankind’s Control of Nature......................... 5 Modernity and Safety Engineering.............................................. 6 The Rise of Safety Institutions...................................................... 8 1.5.1 The Politics of Safety...................................................... 8 1.5.2 Inspectors and Investigators..........................................10 1.5.3 Standards and Professional Associations.................... 12 1.5.4 Insurers, the State, and Workers’ Compensation...... 13 1.6 Safety Science and the Role of the Human................................ 18 Study Questions........................................................................................18 References and Further Reading............................................................19 Chapter 2 The 1910s and Onward: Taylor and Proceduralization...................... 23 2.1 2.2 2.3 2.4 2.5
Introduction................................................................................. 24 The Intersection of Science, Management, and Safety........... 24 2.2.1 Foundations of Procedures and Safety........................24 2.2.2 Taylor and Time Studies................................................25 2.2.3 The Gilbreths and Motion Studies..............................27 2.2.4 Differences and Similarities between Time and Motion Studies.............................................................. 28 2.2.5 Implications for Safety Science....................................30 Procedures, Safety Rules, and “Violations”............................. 32 2.3.1 The Relationship between Safety and Rules...............32 2.3.2 Model 1 and the Scientific Management Legacy...... 34 2.3.3 “Violations” as a Preoccupationof Model 1................37 Model 2: Applying Procedures as Substantive Cognitive Activity......................................................................................... 43 2.4.1 Procedures and the Complexity of Work................... 43 2.4.2 Procedures as Resources for Action............................ 47 2.4.3 Work-as-imagined Versus Work-as-Done...................50 Model 2 and Safety...................................................................... 52 2.5.1 The Limits of Prespecified Guidance......................... 52 2.5.2 Failing to Adapt or Adaptations That Fail.................. 53 v
Vl Contents 2.5.3 Closing the Gap or Understanding It?..................... 54 Scientific Management in Safety Today................................ 54 2.6.1 Workers Are Dumb, Managers Are Smart.............. 54 2.6.2 Taylor and Linear, Closed, Predictable Work..........56 2.6.3 Methodological Individualism................................. 57 Study Questions.................................................................................. 58 References and Further Reading....................................................... 59 2.6 Chapter 3 The 1920s and Onward: Accident Prone...........................................63 3.1 3.2 Introduction............................................................................. 63 The Discovery (or Construction) of Accident-Proneness...... 64 3.2.1 Accident-Prone Workers..............................................64 3.2.2 German Origins of Accident-Proneness...................65 3.2.3 English Origins of Accident-Proneness....................67 3.2.4 French Origins of Accident-Proneness......................69 3.3 The Social Conditions of Possibility...................................... 70 3.3.1 Modernization, Measurement, and Statistics............70 3.3.2 Individual Differences and Eugenics........................ 72 3.3.3 Idiots, Imbeciles, and Morons................................... 73 3.4 Accident-Proneness Today...................................................... 74 3.4.1 The Growth of Dissent................................................74 3.4.2 Recent Studies of Accident-Proneness...................... 76 3.4.3
Accident-Proneness Versus Systems Thinking......... 78 3.5 Expertise and Accident-Proneness..........................................79 3.5.1 Are Experts More Accident Prone?.......................... 79 3.5.2 Expertise and Organizational Vulnerability to Accidents..................................................................... 81 Study Questions....................................................................................83 References and Further Reading.........................................................83 Chapter 4 The 1930s and Onward: Heinrich and Behavior-Based Safety.........87 4.1 4.2 4.3 4.4 Introduction............................................................................... 88 A ‘Scientific’ Examination of Accident Causation.................89 4.2.1 Heinrich’s Study.......................................................... 89 4.2.2 Bird and ‘Damage Control’........................................ 90 Three Pillars of Heinrich’s Theory..........................................94 4.3.1 Injuries Are the Result of Linear, Single Causation...94 4.3.2 The Ratio between Occurrences, Minor Injuries and Major Injuries....................................................... 97 4.3.3 Worker Unsafe Acts..................................................... 98 Behaviorism and BBS................................................................99 4.4.1 Behaviorism, Industrialization, and Progress.......... Ю5 4.4.2 Behaviorism and Industrial Psychology................... 106 4.4.3 Productivity Measures as Safety Measures.............. Ю7
Contents VII 4.5 BBS............................................................................................. 112 4.5.1 Impact across the Decades..........................................112 4.5.2 Does BBS Work?..........................................................116 4.6 Critiques of Heinrich, Behaviorism and BBS.........................119 4.6.1 The Primacy of ‘Human Error’.................................. 119 4.6.2 The Triangle (or Pyramid)...........................................121 4.6.3 Chain-Of-Events Thinking and Decomposition Assumptions.................................................................131 Study Questions.....................................................................................133 References and Further Reading......................................................... 134 Chapter 5 The 1940s and Onward: Human Factors and Cognitive Systems Engineering........................................................................................... 137 5.1 Introduction............................................................................... 138 5.1.1 The Place of Human Factors in the 20th Century.... 138 5.1.2 Human Factors Change Behavior, But Not by Targeting Behavior...................................................... 139 5.1.3 The Emergence of ‘Human Factors’......................... 140 5.1.4 Work Inside and Outside the Research Laboratory.... 144 5.2 Human Factors and Changes in Psychology.......................... 146 5.2.1 Behaviorism: Changing the Legacy.......................... 146 5.2.2 The First Cognitive Revolution:
Information Processing.................................................................... 147 5.2.3 Losing Situation Awareness....................................... 152 5.2.4 The Second Cognitive Revolution..............................156 5.3 Cognitive Systems Engineering...............................................158 5.3.1 Human Error (Again)..................................................158 5.3.2 Jens Rasmussen’s Foundational Work....................... 159 5.3.3 Two Stories of Error.................................................... 162 5.3.4 Increased Socio-Technological Complexity.............. 164 5.3.5 Joint Cognitive Systems..............................................166 5.3.6 Patterns in Cognitive Systems Engineering.............. 174 Study Questions..................................................................................... 183 References and Further Reading......................................................... 184 Chapter 6 The 1950s, 1960s, and Onward: System Safety.................................189 Drew Rae and Sidney Dekker 6.1 6.2 6.3 Introduction................................................................................189 Historical Background...............................................................192 6.2.1 Fly-Fix-Fly.................................................................... 192 6.2.2 Missiles, Nuclear, and Aerospace..............................193 6.2.3 Complexity, Culture, and Computers.........................196 Formal Concepts of System Safety......................................... 197 6.3.1
Hazards...........................................................................197
viii Contents 6.3.2 6.3.3 6.3.4 6.3.5 Risk Assessment.........................................................200 Safety Cases...............................................................203 Reliability and Safety..... .......................................... 204 System Safety and Understanding Complex System Breakdowns.................................................. 207 6.4 System Safety as the Absence of Negative Events?................214 Study Questions................................................................................... 215 References and Further Reading...................... 216 Chapter 7 The 1970s and Onward: Man-Made Disasters.................................. 219 7.1 Man-Made Disaster Theory.................................................... 219 7.1.1 Safety and Social Science......................................... 220 7.1.2 Disasters Do not Come Out of the Blue....................221 7.2 The Incubation Period............................................................. 222 7.2.1 Stages of Incubation...................................................223 7.2.2 Failures of Foresight...................................................227 7.2.3 The Creation of Local Rationality............................229 7.2.4 Studying the ‘Information Environment’..................233 7.2.5 Data Overload............................................................. 239 7.2.6 Groupthink................................................................. 240 7.2.7 Addressing the Barriers: Safety Imagination........... 243 7.3 Models of Drift and Disaster Incubation
after Turner........... 245 7.3.1 Normalization of Deviance....................................... 247 7.3.1.1 Continued Belief in Safe Operations....... 248 7.3.1.2 Goal Interactions and Normalization of Deviance.....................................................249 7.3.2 Practical Drift............................................................. 251 7.3.3 Drift into Failure........................................................ 254 7.3.4 Similarities and Overlap in Drift Models................ 258 7.3.5 Drift into Failure and Incident Reporting................ 259 7.4 Man-Made Disaster Theory and Societal Emancipation......260 Study Questions................................................................................... 262 References and Further Reading........................................................ 263 Chapter 8 The 1980s and Onward: Normal Accidents and High Reliability Organizations.......................................................................................267 Verena Schochlow and Sidney Dekker 8.1 8.2 Normal Accident Theory......................................................... 267 8.1.1 Linear versus Complex Interactions..........................272 8.1.2 Loose versus Tight Coupling......................................274 8.1.3 The Paradox of Centralized Decentralization.......... 276 High Reliability Organizations................................................ 281 8.2.1 The Beginnings of HRO: La Porte, Roberts, and Rochlin........................................................................ 281
Contents ix 8.2.2 Weick and Sutcliffe’s Concept of Mindfulness........285 8.2.3 HRO and the Capacity for Safe Operations.............288 8.3 Sagan and “The Limits of Safety”..........................................290 8.3.1 NAT and HRO in a Historical Case.......................... 290 8.3.2 NAT and HRO in Debate........................................... 293 8.3.2.1 Competitive versus Complementary Approaches..................................................293 8.3.2.2 Are Accidents Preventable?.......................294 8.3.2.3 Tightly Coupled and Interactively Complex Systems........................................294 8.3.2.4 Organizational Structure...........................295 8.3.2.5 Technology and Human Operators.............295 8.3.2.6 Outcome of the Debate................................296 8.4 Further Development..................................................................296 8.4.1 Further Development of NAT................................... 296 8.4.2 Further Development of HRO....................................298 Study Questions.....................................................................................301 References and Further Reading........................................................ 301 Chapter 9 The 1990s and Onward: Swiss Cheese and Safety Management Systems.................................................................................................. 305 9.1 Introduction................................................................................ 306 9.1.1 Thinking about the System Had Been Long in the
Making.................................................................. 306 9.1.2 Impossible Accidents....................................................307 9.2 Swiss Cheese............................................................................. 308 9.2.1 Defenses-In-Depth and Barriers............................... 308 9.2.2 The Impetus for Swiss Cheese...................................310 9.2.3 Resident Pathogens...................................................... 311 9.2.4 Porous Layers of System Defenses.............................314 9.2.5 Shared Assumptions between Reason, Heinrich, and Bird........................................................................ 317 9.3 Linearity, Judgments, and Bureaucratic Order........................319 9.3.1 Linearity and Proportionality..................................... 319 9.3.2 Judgments Rather than Explanations......................... 324 9.3.3 Administrative Ordering and Safety Bureaucracies............................................................ 325 9.4 Swiss Cheese and Safety Management Systems....................327 9.4.1 Directing Attention Away from the Sharp End Alone............................................................................ 327 9.4.2 Demonstrating That Safety Risks Are Well Managed.......................................................................328 9.4.3 The Safety of Work, or the Work of Safety?.............330 Study Questions..................................................................................... 335 References and Further
Reading......................................................... 336
x Contents Chapter 10 The 2000s and Onward: Safety Culture........................................... 339 10.1 The Origins of Safety Culture............................................... 340 10.1.1 Continuing the Trend into the Blunt End.................340 10.1.2 Political Origins.........................................................341 10.1.3 Theoretical Origins................................................... 345 10.1.4 Safety Climate............................................................347 10.2 Safety Culture Today...............................................................348 10.2.1 What Is It Exactly?.................................................... 348 10.2.2 A Functionalist Approach to Safety Culture............ 351 10.2.3 An Interpretivist Approach to Safety Culture..........359 10.3 Problems and Critique............................................................. 363 10.3.1 Cultures That Are ‘Better’ or ‘Worse’..................... 363 10.3.2 Consistency and Agreement Versus Conflict and Contradiction...................................................... 366 10.3.3 Safety Culture and Power.......................................... 368 10.3.4 Methodological Individualism..................................370 10.3.5 Is Safety Culture Useful for Regulators or Investigators?.............................................................. 372 10.3.6 Do Safety Culture Assessments Have Predictive Value?........................................................379 10.3.7 Safety Culture Says so Much, It Ends up Saying Very
Little......................................................385 Study Questions.................................................................................. 387 References and Further Reading........................................................388 Chapter 11 The 2010s and Onward: Resilience Engineering............................. 391 Johan Bergström and Sidney Dekker 11.1 11.2 11.3 11.4 11.5 The Need for Resilience.......................................................... 391 11.1.1 Resilience Engineering as the Assurance of Capacity to Adapt.......................................................391 11.1.2 Resilience and Complexity........................................ 395 11.1.3 Complex Systems Operate Farfrom Equilibrium.... 398 11.1.4 Resilience in Other Fields......................................... 399 Resilience Engineering as a New Discipline in Safety Science...................................................................................... 402 Resilience Ideas of Rasmussen, Woods, and Hollnagel...... 410 11.3.1 Tracing Resilience Engineering to the Risø Community in the 1980s................................... 410 11.3.2 Woods: The Adaptive Universe................................. 413 11.3.3 Hollnagel: Cornerstones, Functional Resonance, and Trade-Offs........................................................... 414 Dimensions of Resilience Engineering................................. 417 Three Analytical Traps for Resilience Scholars to Avoid.... 418 11.5.1 The Reductionist Trap................................................418
Contents xi 11.5.2 The Moral Trap........................................................... 420 11.5.3 The Normative Trap....................................................422 Study Questions.................................................................................... 424 References and Further Reading.........................................................424 Postscript............................................................................................................. 431 Index..................................................................................................................... 437
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| spelling | Dekker, Sidney Verfasser (DE-588)138148813 aut Foundations of safety science a century of understanding accidents and disasters Sidney Dekker Boca Raton ; London ; New York CRC Press [2019] xxi, 445 Seiten Illustrationen txt rdacontent n rdamedia nc rdacarrier Includes index Gefährdungsanalyse Arbeitsschutz (DE-588)4198785-8 gnd rswk-swf Arbeitssicherheit (DE-588)4068817-3 gnd rswk-swf Industrial safety / History Industrial accidents / History Industrial accidents Industrial safety History Electronic books Arbeitssicherheit (DE-588)4068817-3 s Gefährdungsanalyse Arbeitsschutz (DE-588)4198785-8 s DE-604 Erscheint auch als Online-Ausgabe 978-1-351-05979-4 Digitalisierung UB Bamberg - ADAM Catalogue Enrichment application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=031293746&sequence=000001&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Dekker, Sidney Foundations of safety science a century of understanding accidents and disasters Gefährdungsanalyse Arbeitsschutz (DE-588)4198785-8 gnd Arbeitssicherheit (DE-588)4068817-3 gnd |
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| title | Foundations of safety science a century of understanding accidents and disasters |
| title_auth | Foundations of safety science a century of understanding accidents and disasters |
| title_exact_search | Foundations of safety science a century of understanding accidents and disasters |
| title_full | Foundations of safety science a century of understanding accidents and disasters Sidney Dekker |
| title_fullStr | Foundations of safety science a century of understanding accidents and disasters Sidney Dekker |
| title_full_unstemmed | Foundations of safety science a century of understanding accidents and disasters Sidney Dekker |
| title_short | Foundations of safety science |
| title_sort | foundations of safety science a century of understanding accidents and disasters |
| title_sub | a century of understanding accidents and disasters |
| topic | Gefährdungsanalyse Arbeitsschutz (DE-588)4198785-8 gnd Arbeitssicherheit (DE-588)4068817-3 gnd |
| topic_facet | Gefährdungsanalyse Arbeitsschutz Arbeitssicherheit |
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