ABSTRACT

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.

chapter |2 pages

Part I Errors and Complex Systems

chapter 1|8 pages

Introduction

part |2 pages

Part II Antecedents

chapter 3|16 pages

Equipment

chapter 4|16 pages

The Operator

chapter 5|16 pages

The Company and the Regulator

chapter 6|12 pages

Maintenance and Inspection

chapter 7|16 pages

Multi-Operator Systems

chapter 8|12 pages

Culture

part |2 pages

Part III Data and Data Analysis

chapter 9|14 pages

System Recorders

chapter 10|12 pages

Written Documentation

chapter 11|22 pages

Interviews

chapter 12|26 pages

Analysis

part |2 pages

Part IV Issues

chapter 13|20 pages

Situation Awareness and Decision Making

chapter 14|16 pages

Automation

chapter |2 pages

Part V Applying the Data

chapter 15|26 pages

Case Study

chapter 16|6 pages

Final Thoughts