The Field Guide to Understanding Human Error Paperback – Jun 30 2006
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Insightful, useful, refreshing. A must-read for anyone tired of the "old view" of human error'Boyd Falconer, University of New South Wales, Australia'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' 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, Sid's 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
About the Author
Sidney Dekker is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University in Brisbane, Australia. Previously Professor at Lund University, Sweden, and Director of the Leonardo Da Vinci Center for Complexity and Systems Thinking there, he gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has worked in New Zealand, the Netherlands and England, been Senior Fellow at Nanyang Technological University in Singapore, Visiting Academic in the Department of Epidemiology and Preventive Medicine, Monash University in Melbourne, and Professor of Community Health Science at the Faculty of Medicine, University of Manitoba in Canada. Sidney is author of several best-selling books on system failure, human error, ethics and governance. He has been flying the Boeing 737NG part-time as airline pilot for the past few years. The OSU Foundation in the United States awards a yearly Sidney Dekker Critical Thinking Award.
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Top Customer Reviews
If you want real and effective corrective actions to events at your facilities, this is a must read. Also see "Managing the Risks of Organizational Accidents" by James Reason / Ashgate, 1997 and Revs.
Most Helpful Customer Reviews on Amazon.com (beta)
Dekker tries to put himself in the shoes of that human operator showing why an analysis that does not try to understand an event from that position is useless.
There is a very hard criticism to different kind of positions taken by people that do not make that effort.
If we try to make something as a "winzip on a summary" of the book, I think we could reach these conclusions:
When we have to analyze an event, it should be useful starting with this hipothesis: "People are not usually dumb, people are not usually crazy and people have not usually chosen the day of a big accident to make self-killing." This starting point could be enough to avoid many of the practices fairly critiziced by Dekker.
We live in the information age now; the only way to improve our lot is to share information for the purpose of continual learning. Dekker's approach points the way.
This particular book purports to be a 'field guide', implying that it has a 'how to' orientation. To some extent it does, but it should be clarified that the focus is *understanding* human error, not investigating it or preventing it (and the book challenges the utility of the concept of 'human error'). As such, the main goal of the book appears to be presenting a theoretical framework for thinking about safety which Dekker, as a member of the safety research community, has developed over the past two decades. The core elements of this framework might be summarized as follows:
(1) Many of the systems we deal with are complex, with interactions of both human and physical factors.
(2) Complex systems aren't inherently safe, their natural tendency is to drift towards failure.
(3) We don't see more failures than we do because people, generally being well intentioned, are continually making an effort to cope with the pressures they face to achieve various goals, while simultaneously trying to avoid failures and maintain safety. This usually requires transcending formal rules and procedures in order to adapt to the needs of particular dynamically evolving circumstances. But sometimes these efforts do fall short, cumulatively over time, hence we have some failures.
(4) To understand why people's efforts fall short, both individually and collectively, we need to avoid hindsight bias and instead put ourselves in their shoes, to understand why their decisions and actions made sense to them at the time. This shifts the meaning of 'human error' to being an act which simply contributed to an undesired outcome, rather than an act resulting from carelessness, complacency, overconfidence, etc. But ironically and unfortunately, a long record of success *can* foster complacency or overconfidence which increase the risk of failure.
(5) Putting ourselves in people's shoes will often reveal problems with the way the organization is operating overall, and those problems are where are efforts for reform should be directed, rather than seeking to simply identify and eliminate bad apples. More automation will often not be the answer, since it can insulate us from the operational reality of the system and wind up contributing to failures. By contrast, improving flow of information within the organization will usually be helpful.
(6) Much resistance is likely to be encountered when trying to implement such reform and establish a 'safety culture'. So safety departments should have both independence and sufficient resources, while still having close exposure to the daily operational reality of the organization.
I can certainly recommended this book, but again keep in mind that much of the content can be found in Dekker's other books. Also keep in mind that, while Dekker may be considered essential reading for anyone interested in safety, it's also important to read other authors to hear different perspectives. I suspect that Dekker himself would agree with that advice!
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