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The Field Guide to Understanding Human Error

by Sidney Dekker

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1453190,220 (4.22)6
When faced with a 'human error' problem, you may be tempted to ask 'Why didn't these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it. Building on its successful predecessors, the third edition of The Field Guide to Understanding 'Human Error' will help you understand a new way of dealing with a perceived 'human error' problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a 'human error' problem, abandon the fallacy of a quick fix. Read this book.… (more)
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There’s a reason that “human error” is in quotation marks in the title of this book. “Human error” is only an error in hindsight; if you’re investigating an accident, you have the luxury of knowing the outcome and what the people involved did “wrong”. Talking about “human error” comes from an assumption that a system is inherently safe and that it’s pesky humans that make it unsafe with their not following procedures and losing situational awareness and becoming complacent (whatever THAT means). But this is not how reality works. People don’t show up at work intending to have an accident. They work in messy, complicated systems, sometimes with workarounds to get the job done.

So human error, blaming, and finding what went wrong is the “old view” of safety. In this book, Sidney Dekker explains the “new view” of safety, one that has as its basis the idea that people don’t come to work to do a bad job, that we need to see the accident scenario from the point of view of the participants (who did not know how their day was going to turn out), to figure out why they did what they did, and to examine the operating context in which they are working. Not only that, but also examining how resilient a system is: after all, things go right more often than they go wrong. What makes a system resilient, and can you use that information to prevent future accidents? Dekker explains these concepts clearly and with humour, and draws on actual accident investigation reports to illustrate his points.

The only reason this isn’t a full five stars is that I found some of the formatting weird (why were some passages made to look like block quotes if they weren’t direct quotes from another publication?). But the content is what really matters here, and it’s very well done. Endnotes at the end of each chapter, and the whole last chapter is a list of further reading, with explanations of why they are useful books to read—I love when authors do that with a “further reading” list.

Recommended if you are interested in accident investigation, safety, or why people do what they do. ( )
  rabbitprincess | May 30, 2020 |
This book is an absolute must read for anyone "in charge of" or responsible for people. Superb view on "human error". ( )
  MikePearce | Jun 19, 2017 |
Fascinating and very interesting! ( )
  librarymary09 | May 24, 2014 |
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When faced with a 'human error' problem, you may be tempted to ask 'Why didn't these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it. Building on its successful predecessors, the third edition of The Field Guide to Understanding 'Human Error' will help you understand a new way of dealing with a perceived 'human error' problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a 'human error' problem, abandon the fallacy of a quick fix. Read this book.

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