The Human Contribution

Unsafe Acts, Accidents and Heroic Recoveries

James Reason

За особеностите на екземпляра

Състояние:: Много добро
Забележка:: Печат на първа страница.
Език:: Английски
Наличност:: 1 бр.

За изданието

Издателство:: Ashgate
Година:: 2008 г.
Език:: Английски
Страници:: 295
Корици:: Меки
Категория:: Научно-популярна литература
Ширина (мм):: 160
Височина (мм):: 234
Дебелина (мм):: 20
ISBN:: 9780754674023

Contents List of Figures List of Tables About the Author PART 1 INTRODUCTION Chapter 1 The Human Contribution: Hazard and Hero Introduction The structure of the book About the book Chapter 2 A Mind User's Guide Tip-of-the-tongue state The conscious and automatic modes of control Three levels of performance Interacting with the long-term knowledge base Intentions and the retrieval cycle Concurrent processing The relationship between memory and attention: the blob-and-the-board model Summing up PART II UNSAFE ACTS Chapter 3 The Nature and Varieties of Human Error Defining and classifying error Error myths Slips and lapses Rule-based mistakes Knowledge-based mistakes Conclusion: a general rule Contril Chapter 4 Violations and the Varieties of Rule-related Behaviour Chernobyl and Zeebrugge Violations considered as unsafe acts Who is most likely to violate? Why do people violate safety rules? The 'mental economics' of violating Bad procedures Procedure-usage Testing two models of violating behaviour The varieties of rule-related behaviour Great improvisers End piece Chapter 5 Perceptions of Unsafe Acts The plague model The person model The legal model The system perspective Person and system models: getting the balance right PART III ACCIDENTS Chapter 6 Error Traps and Recurrent Accidents Accident proneness: a quick survey Everyday error traps Recurrent accident patterns The elements of recurrent scenarios Cultural drivers Conclusion Chapter 7 Significant Accident Investigations Problems with the past Changes in accident investigation The Mahon and Moshansky reports Has the pendulum swung too far? Conditions and causes Counterfactual fallacy The current view buchhaus.com PART IV HEROIC RECOVERIES Chapter 8 Training, Discipline and Leadership The Light Division's retreat at Fuentes de Onoro (1811) The withdrawal of the 1st Marine Division from Chosin Reservoir (1950) Concluding remarks Chapter 9 Sheer Unadulterated Professionalism Captain Rostron and the rescue of the Titanic survivors (1912) Saving Apollo 13 (1970) British Airways Flight 09 (1982) The BAC 1-11 incident (1990) Surgical excellence (1995-97) Minor and major events Concluding remarks Chapter 10 Skill and Luck The Gimli Glider Captain Al Haynes and United 232 Final word Chapter 11 Inspired Improvisations General Gallieni and the Paris taxis Captain Gordon Vette and the rescue of Jay Prochnow Conclusion The Ingredients of Heroic Recovery Chapter 12 Coping with expected hazards Coping with unlikely but possible hazards Generic qualities Conclusion PART V ACHIEVING RESILIENCE Chapter 13 Individual and Collective Mindfulness Consistency versus variability A dynamic non-event Collective mindfulness Individual mindfulness Aspects of resilience Foresight training at the UK National Patient Safety Agency Organisational support Looking towards the future Mindfulness and resilience Chapter 14 In Search of Safety Introduction What does the term 'safety' mean? The two faces of safety The 'safety space' model What does a resilient system look like? The knotted rubber band model Defining the nature of positive safety Final words List of Figures Figure 2.1 Three levels of performance control Figure 2.2 The 'blob-and-the-board' model Figure 5.1 First version of the Swiss cheese model (though it hadn't yet taken on its Emmenthale appearance. Various human contributions to the breakdown of complex systems are mapped on to the basic elements of production Figure 5.2 Part of the earliest version of the Swiss cheese model. The diagram shows a trajectory of accident opportunity penetrating several defensive layers, and begins to have Emmenthaleish features Figure 5.3 The early 90's variant of the Swiss cheese model Figure 5.4 A mid-90s variation with two interacting pathways to an accident Figure 5.5 The latest version of the Swiss cheese model Figure 6.1 Showing the unequal liability to accidents in a group exposed to the same hazards over the same time period. The curve represents the chance prediction of event likelihood (Poisson distribution). The columns represent the actual number of accide Figure 6.2 Kanizsa Triangle Figure 7.1 Tracing the shifting emphases of accident investigations Figure 8.1 The manoeuvres required in preparing to receive cavalry on the march. Figure 8.2 The Battle of Fuentess de Onoro, 5th May 1811 Figure 8.3 Showing the area over which the Chosin Reservoir campaign was fought The Human Contril Figure 9.1 A cutaway diagram of the service module, It was the round cryogenic oxygen tank (second layer) that exploded and nearly destroyed the spacecraft Figure 9.2a Surgical defences in the arterial switch operation represented as Swiss cheese slices in which the holes do not line up Figure 9.2b Using the Swiss cheese model to represent a typical major event scenario Figure 9.3a The slice of Cheddar at the left hand end represents coping abilities Figure 9.3b The mouse nibbling at the slice of Cheddar represents how adverse events, both major and minor, can eat away at limited coping resources Figure 11.1 Flying the aural box pattern into the VHF range circle Figure 13.1 Combining individual and collective mindfulness to enhance patient safety Figure 13.2 The 'three-bucket model for assessing high-risk situations Figure 13.3 How the bucket contents might be interpreted Figure 13.4 Tracing the possible progress of developments in patient safety Figure 13.5 Showing the reduction in variability as the cycle progresses Figure 14.1 Illustrating vulnerability and resistance. The arrows at the top of the figure represent perturbing forces Figure 14.2 Showing a number of hypothetical organisations within the same hazardous domain distributed throughout the safety space Figure 14.3 Summarising the driving forces and navigational aids necessary to propel an organisation toward the region of maximum resistance Figure 14.4 Three states of the knotted rubber band Figure 14.5 Showing the resource implications of the knotted rubber band model List of Tables Table 2.1 Comparing the properties of the conscious workspace and the long-term knowledge base Table 3.1 Comparing the properties of exceedances, incidents and accidents Table 4.1 Summarising the violation 'balance sheet' Table 4.2 Summarising the 12 varieties of rule-related behaviour Table 5.1 Comparing the CANDU and RBMK safety features Table 7.1 Three examples of the distinction between cause and condition Table 14.1 Summarising the interactions between reactive and proactive measures Table 14.2 Combining the 3Cs and the 4Ps to produce 12 sets of indicators