The field guide to understanding Human Error – Sidney Dekker
All too often we still see accident reports which have a conclusion of “Human Error” which reveals us exactly nothing.
The basic idea of the book is “Human error is where a investigation should start, not where it should end”.
After the fact analysis has many traps that investigators might fall into simply due to the different post-hoc perspective.
If you are involved in Safety Investigations this is an essential book to understand some of the biases you as an investigator might suffer that might get in the way of understanding events, incidents and accidents.
There is also a good section which describes the role of the safety department.
As Sidney Dekker has a second side-career as a commercial airline pilot, besides his main occupation as Professor of Human Factors and Flight Safety, this book is very relevant to aviation with many good examples.
(Don’t confuse this book with “The field guide to Human Error Investigations” by the same author which can be considered the first edition and is not such an effective book.)
From the Amazon page:
When faced with a human error problem, you may be tempted to ask ‘Why didn’t they watch out better? How could they not have noticed?’. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. 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. This old view of human error is increasingly outdated and will lead you nowhere. The new view, in contrast, understands that a human error problem is actually an organizational problem. Finding a ‘human error’ by any other name, or by any other human, is only the beginning of your journey, not a convenient conclusion. The new view recognizes that systems are inherent trade-offs between safety and other pressures (for example: production). People need to create safety through practice, at all levels of an organization. Breaking new ground beyond its successful predecessor, “The Field Guide to Understanding Human Error” guides you through the traps and misconceptions of the old view. It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language. But it also helps you look forward. It suggests how to apply the new view in building your safety department, handling questions about accountability, and constructing meaningful countermeasures. It even helps you in getting your organization to adopt the new view and improve its learning from failure. So if you are faced by a human error problem, abandon the fallacy of a quick fix. Read this book.
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