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If you design equipment or operating procedures, if you investigate accidents or deal with safety, this is an essential book. Sidney Dekker, a leading world authority on "human error" has enhanced his already exceptional "Field Guide to be a concise, readable guide to both design of equipment and procedures and also the analysis of mishaps. The label "human error' is misleading and its use prevents discovery and correction of the true underlying causes of incidents.
So mad about hindsight bias, about the difference between the view from inside the system rather than from outside, and about diffe rence between the blunt end (whereyou should doyour work) and the sharp end (where people tend to focus). Read, learn, and put these ideas into practice. The results will be fewer incidents, less damage, less injury. When faced with a 'human error problem, you may be tempted to ask 'Why didn't these people watch out better ? ' Or,'-low 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 3rd edition of The Field Guide to Understanding 'Human Error' helps you understand a new way of dealing with a perceived 'human error' problem in your organization. It helps you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations.
You will learn that you are not the custodian of an already safe system which you need to protect from erratic people. Instead, you will see how people create safety through practice, everyday, throughout your organization. They do this mostly successfully, even under the pressure of resource constraints and multiple conflicting goals. This 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.