Book Description
Modern technology has now reached a point where improved safety can only be achieved through a better understanding of human error mechanisms. In its treatment of major accidents, the book spans the disciplinary gulf between psychological theory and those concerned with maintaining the reliabiblity of hazardous technologies. Much of the theoretical structure is new and original, and of particular importance is the identification of cognitive processes common to a wide variety of error types.
Customer Reviews:
Avoiding and Managing Errors.......2006-05-07
This is a seminal work for anyone working in hazardous industries. I work in the aviation industry and I found this book to be so enlightening and useful. Whilst industry should always strive towards ensuring that errors do not occur in the first place, it will never be possible to eradicate them totally. Therefore all organisations should aim to `manage' errors. Professor Reason refers to the two components of error management namely error containment and error reduction.
To prevent errors from occurring, it is necessary to predict where they are most likely to occur and then to put in place preventative measures. Incident reporting schemes do this for the industry as a whole. Within an organisation, data on errors, incidents and accidents should be captured with a Safety Management System (SMS), which should provide mechanisms for identifying potential weak spots and error-prone activities or situations. Output from this should guide local training, company procedures, the introduction of new defences, or the modification of existing defences.
According to Reason, error management includes measure to reduce the error susceptibility of particular tasks or task elements; determine, assess and then remove error-producing factors within the workplace; identify organisational issues that generate error-producing factors within the individual, the team, the task or the workplace; improve error detection; increase the error tolerance of the workplace or system; make latent conditions more visible to those who operate and manage the system; improve the organisation's intrinsic resistance to human fallibility.
It is important that organisations balance profit and costs, and try to ensure that the defences which are put in place are the most cost-effective in terms of trapping errors and preventing catastrophic outcomes.
Reason teaches that error management seeks to prevent errors from occurring and eliminate or mitigate the bad effects of errors. One of the things likely to be most effective in preventing error is to make sure that people follow procedures. This can be effected by ensuring that the procedures are correct and usable, that the means of presentation of the information is user friendly and appropriate to the task and context, that employees are encouraged to follow procedures and not to cut corners.
This is a well written book that is a must read for anyone working in hazardous industries where safety is number one priority.
Best the third time through.......2003-09-28
This book is a very complete and well done review of the history and mechanisms of human error. I can't think of a better reference book. It takes some work to extract the knowledge from the rather concentrated material, but it is well worth it. I generally like an easier, novel-type read, but there are plenty of other books on human factors that provide that. This one shines in the very systematic and complete treatment of the subject. And the bibliography is excellent, because it facilitates the easy branching out into all of his sources. Speaking of people mentioned, I knew I would like it when he spoke highly of Donald Norman. He also mentions Perrow's 'Normal Accidents', which is an excellent book. Also the quote from Ernst Mach can lead into a fascinating side trail of discovery on that man. But mainly his dedication of the book to Jens Rasmussen sent me off on a trail of his work, which is quite prolific. I think this is academia at its best - building on the work of predecessors to help further development of tools and understanding on how to solve practical, real world problems.
Best Resource for Latent Human Errors.......2002-05-02
This book is a must have resource for the serious failure analyst. I am responsible for root cause analysis of events at a nuclear power station and we have this as required reading for our root cause analysts.
Furthermore, my experience with other companies who specialize in failure analysis and nuclear industry oversight agencies indicates that the information presented in this book is widely used and respected. More than that - the information helps you to prevent events and solve recurring problems because you get to the latent organizational and human roots.
My copy has gotten dog-eared and has all kinds of notes in the margins. It's absolutely indespensible as a resource for any organization where a strong safety culture (for your employees and your customers) is a necessary part of your business.
Human Error - by James Reason.......2002-01-10
An excellent treatise on the subject of human error, written with a cognitive psychology approach. The treatment of the subject matter is more theoretical and less practice-oriented. The book begins with clear definitions, classifications and explanations on the different types of errors, quickly runs through the relevant literature and scientific studies and expands on the typology using Rasmussen's classification as a base. The author then goes on to describe his well-known Swiss Cheese model and provides an excellent overview of accident causation from a system-thinking perspective. He ends with a note on the methodological assessment of error risks which is perhaps more relevant to safety practitioners. The entire book is written in clear simple language that is easily understood, fascinating and intellectually stimulating, even to non-psychologists.
The fundamentals.......2000-05-17
Anyone with any interest in error reduction, or in the way humans interact with technology should start here. The psychological analysis of how and why we commit errors is fascinating, and influences the way one thinks about daily events. I find myself saying "Aha, that was a capture error," and "Damn! I've fallen for the fundamental attribution error again." The real lesson is that errors derive from the very nature of human behavior--the mechanisms which enable us to solve complex problems also make errors inevitable. This realization changes entirely one's concept of industrial accidents and medical mistakes.
Customer Reviews:
Not the Full Monty........2007-10-08
My main interest in this subject lies in a search for answers to the question of why perfectly sane and intelligent people put faith in God above reasoning. Why do so many choose to believe so strongly with so little evidence? Unfortunately Thomas Gilovich absolutely refuses to cast light on religious delusions, but mainly states that theists and atheist "both need to develop the habit of thinking more broadly." Not helpful at all and sort of a faux pas to include this lame comment in the book.
Never the less, the book is a good and thorough introduction to the subject of our penchant for faulty reasoning, but also somewhat dry and repetitive. I wasn't exactly rolling on the floor with laughter, which might be too much to ask; but the many examples and anecdotes could be presented with greater vigour without harming the seriousness and validity of the study.
May I recommend: "Don't Believe Everything You Think: The 6 Basic Mistakes We Make in Thinking" by Thomas E. Kida, which is very similar in content and reference a lot of the same sources, but is also more playful and entertaining.
Vulcans Should Read This Book.......2007-06-02
Hello, my name is Mr. Spock. You may know me from the TV series StarTrek. For years I've been tormented by the illogic of humans. Let's face it, Captain Kirk and Dr. McCoy are not the sharpest phasers in the intergalactic utility belt!
Then I read Gilovich's book. It helped me realize that humans are most illogical in times of uncertainty when there is no clear trend and not enough information upon which to make a good decision. In such cases, especially when a decision must be made, logic is not going to be of much help. As a result, people develop simple, but often inaccurate, theories to help them through painful states of indecision. The decision may be good or not, but at least a decision has been made, and that alone provides comfort.
Unfortunately, humans also have a strong desire to justify their theories, and this is where they get into trouble. Data that proves the theory is retained and emphasized, and data that doesn't is heavily discounted. So the theory takes on a life of its own despite the facts, which admittedly may themselves be ambiguous at times.
The bottom line is that this book gave me a greater understanding of humans. As a result, I feel more comfortable communicating with them, and just being around them in general. If you're part Vulcan like I am, or even a logical human, I strongly suggest you read this excellent book about human thinking and decision making. You won't be sorry. Live long and prosper!
Mr. Scot, I have completed my Amazon review, and have obtained the Chinese food and pornography magazines the Captain has requested. Please beam me up now.
Question your assumptions and challenge what you think you know.......2006-08-24
This book provides a well-organized survey of issues that limit our reasoning abilities:
- Our misperception of random events, as in the "clustering illusions" that lead us to believe in the hot hand, for example.
- Our misunderstanding of statistical regression, which, for instance, affects our perception of the roles of reward and punishment in education.
- Our tendency to seek confirmatory information, as in the justification of our choices.
- Our inability to see what could have happened under different circumstances, as in self-fulfilling prophecies (e.g. a negative first impression or the presumed insolvency of a financial institution).
- Our own biases that make us expose inconsistent information to more critical scrutiny than consistent information.
- Asymmetries that distort what we recall and, thus, what we take into account to evaluate the validity of beliefs (as in multiple endpoints situations or one-sided events).
- Our tendency to believe what we want to believe (specially about ourselves), as if beliefs were possessions.
- The distortions present in secondhand information (a.k.a. sharpening and leveling).
- The influence of what we think others believe (and also of the inadequate feedback we often receive about that).
These limitations make us draw incorrect conclusions and bolster erroneous beliefs. Being aware of them helps us in distinguishing what we know well from what we only think is true. Just this is of utmost importance for thinking clearly. Could there be a better reason for reading this book?
Should Have Been Better Than It Was.......2006-07-29
Gilovich starts this book of with a real bang! After reading the Introduction, I thought this book would be really interesting and change the way I look at the world. He writes in a college-teacher tone that will not be approachable to those he most needs to reach. In other words, I really don't need a book to tell me to avoid holistic cretins, ESP, psychics, mysticism, and all that other garbage.
The first half of his book is concerned with a review of the psychology literature from the '70s and '80s on how people arrive at their beliefs. This is boring and somewhat like a set of lecture notes. The information in it is useful, but it could be summarized and edited. The second half of the book is devoted to why people shouldn't believe in the topics I mentioned above. Most people who read his book wouldn't even dream of subscribing to these beliefs, so the whole second half is pretty boring.
Gilovich finishes the book by telling us that psychologists are best at understanding the world and are the most perceptive professionals out there, bar none. While admitting that the core thought processes that lead to logical decision making come from hard science, Gilovich wants us to believe that the softies have perfected clear thinking about the world. He should have reread that portion of the book when he wasn't overheated and realized how silly it would sound to attorneys, physicians, scientists, and other thoughtful people.
Required for all psychology students!!!.......2006-06-21
This book is a contemporary classic that should be required reading in all psychology programs. As a psychologist, I am regularly appalled by how few trained psychologists know of the research discussed in this book, indeed, of decision science in general!! It only goes to show, there's scientific psychology (of which this book qualifies), and then, well, there's the other 99%...the crap, fluff, unsupported, unscientific, claims and practices that arise out of pseudo-scientific approaches, misinterpretations of data, and fallacious assumptions and conclusions. As an exemplar of what's good in a field rife with methodological manure and hocus pocus B.S. (e.g. psychotherapy, psychiatry, etc.), this book really shines. Read it and discover why some of psychology really is a science.
Book Description
Since Descartes famously proclaimed, "I think, therefore I am," science has often overlooked emotions as the source of a person's true being. Even modern neuroscience has tended, until recently, to concentrate on the cognitive aspects of brain function, disregarding emotions. This attitude began to change with the publication of Descartes' Error in 1995. Antonio Damasio—"one of the world's leading neurologists" (The New York Times)—challenged traditional ideas about the connection between emotions and rationality. In this wondrously engaging book, Damasio takes the reader on a journey of scientific discovery through a series of case studies, demonstrating what many of us have long suspected: emotions are not a luxury, they are essential to rational thinking and to normal social behavior.
Customer Reviews:
Too much speculation.......2007-03-23
If you want to read about scientific facts this is not the book for you. The scientific underpinnings of this speculative book are briefly mentioned and not elaborated upon in much detail. It's better to just read his paper on the somatic marker hypothesis (which is disputed by the way). Without a background in neuroscience it is difficult to evaluate his ideas in a serious way, and anyway he asks for introspection (a la William James) from the reader more than anything else.
Tom Cruise for President........2007-02-24
If Dr. Damasio is so smart then why doesn't he admit that his thesis implies phrenology? A: because he knows that it is a pseudoscience.
Thoughtful analysis of how the mind works........2006-10-30
The French philosopher René Descartes could not have been more wrong, according to Antonio Damasio, a neurologist at the University of Iowa College of Medicine. Descartes thought the mind was completely separate from the body - an immaterial "thinking thing," the essence of which was cool conscious reasoning untainted by base physical influence. Through his research on patients with prefrontal cortex damage, Damasio discovered that reason, like almost all mental processes, is "embodied," that is, based in the human being's physical self. Emotions and other states that are rooted in physicality profoundly influence not only what people reason about, but how they reason. Without them, people either can't make decisions or they make self-defeating ones. This book tells how Damasio created, developed and tested his theory of embodied cognition, which is now widely influential in psychology, neuroscience and behavioral economics. We recommend this refreshingly nuanced, conversationally told (though sometimes desultory) narrative of scientific invention and discovery to readers who want to learn about this profound, influential set of ideas from the source. You will never think about your mind the same way again.
Damasio concludes: "I am, Therefore I think.".......2006-09-09
"Descartes' Error" begins with the classic head-injury tale of Phinaes Gage - a man who lost a large section of his brain, and lived. "Gage was no longer Gage" his friends said after the accident. Gage's soul, his identity drastically changed. This, Damasio argues, proves materialism. There is no mind/body duality; the mind and the body are one.
The best parts of the book are the stories told of various brain injury cases which Damasio investigated. One patient had a brain tumor removed - and all of his emotions were removed with it. Intellectually, the patient was fine. But he was incapable of caring about anything. As a result, he had a terrible time making future plans.
The trouble with "Descartes' Error" is Damasio's tendecy to go on academic rants, spinning theories on how emotions create character traits in our brains by using feedback loops... (add technical words here, followed by medical terms) etc. I skimmed the chapters on emotion. These theories about how emotions are the seat of the soul - are rife with rambling, dry, academic speculations.
Too bad only half the book is devoted to neurological oddities - such as, a patient whose entire left side of his body is paralyzed, but incapable of realizing that anything is wrong. This stuff I find endlessly fascinating.
If you wish to read a book about weird neurological happenings, check out "A Brief Tour of Human Consciousness: From Impostor Poodles to Purple Numbers" by V. S. Ramachandran. If you want brain philosophy, read Daniel Dennett.
A Biological Basis for Emotion and Logic.......2006-08-16
Damasio attempts nothing less than the quantification of the soul by identifying the likely structures of the brain -- the prefrontal lobes among others -- responsible for logic, reason, emotion and personality. He recounts several stories of patients with prefrontal damage and the peculiar symptoms they display -- then tests his theories with a number of clever experiments carried out in his lab at the University of Iowa. His conclusions are persuasive and well-thought out, and will cause you to re-evaluate much of what you THINK you know about the role of emotion in logical reasoning.
However, the book is flawed in a couple of different directions.
1. The text alternates between well-written, smooth-flowing, extremely readable sections and dense, highly-technical, grammatically-gnarled sentences such as, "In terms of the prefrontal cortices, I am suggesting that somatic markers, which operate on the bioregulatory and social domain aligned with the ventromedial sector, influence the operation of attention and working memory within the dorsolateral sector, the sector on which operations on other domains of knowledge depend [page 198]." Too many sentences of this opacity slowed reading speed to a crawl, and made me wonder about his intended audience.
2. Numerous and frequent references are given to other researchers in the field, but he very rarely elaborates on the directions or results of their research. As a non-academic I am not going to dig out the original articles for myself, and would have preferred Damasio himself provide the summaries.
3. One researcher frequently cited is named "Hanna Damasio" (who coincidentally is also the illustrator of the book) but no mention is made of her relationship to the author. A courtesy explanation would have been in order.
4. The author expresses the usual scientific caution about over-generalizing or drawing broader implications from his work. However, it seems to me the most exciting possibility deriving from his research is exactly that, a biological basis for emotion. I think he would have been forgiven for throwing caution to the winds in the last chapter or two and speculating wildly about the connections between emotional exuberance and brain structure abnormalities, or oppositely emotional monotony and the biologic cause. As it is, his work is solid but measured, which downplays the truly groundbreaking nature of it.
Average customer rating:
- The committee approach
- Everyone should read this book
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To Err Is Human: Building a Safer Health System
Committee on Quality of Health Care in America , and
Institute of Medicine
Manufacturer: National Academies Press
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Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans
ASIN: 0309068371 |
Customer Reviews:
The committee approach.......2000-05-17
This is a book which, despite being written by a committee and showing it, has a definite point of view. It is somewhat superficial, but contains a fairly good review of the literature on medical error and some definite ideas about what to do. This is the book for policy wonks who are interested both in health care and in government intervention. Those looking for more in-depth treatment of the subject would do well to consider Human Error in Medicine, edited by Marilyn Sue Bogner.
Everyone should read this book.......2000-05-16
This eye opening book exposes the dangers of the medical health care system in the United States. Tens of thousands of people die and are injured every year due to doctors' errors, administrative foul ups, misdiagnoses, and incorrect prescriptions. The book gives general solutions for the system as a whole and advice to the individual to help you protect yourself when you are being treated by a doctor or hospital.
My spouse is a Medical Malpractice attorney and you would not believe the frequency of tragic and catastophic errors made by health care providers that change and end people's lives unnecessarily. It can happen to anyone without warning. Protect yourself and purchase this book today for a no nonsense look at the system you may one day depend on to save your life.
Average customer rating:
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The Field Guide to Understanding Human Error
Sidney Dekker
Manufacturer: Ashgate Publishing
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Managing Maintenance Error: A Practical Guide
ASIN: 0754648265 |
Customer Reviews:
Breathes life into accident reports.......2007-08-10
The authors have applied insights from cognitive psychology to nineteen flight-crew-related accidents. In place of the dry narratives of accident reports, we are presented with compelling three-dimensional accounts in which pilots are routinely faced with time pressure, the need to make judgments under uncertainty, and rare but potentially lethal system failures. In examining each accident, the authors attempt to reconstruct the mindset of the pilots, and place the actions of the crew in the context of the flow of events. In contrast to other reviews of accidents, the authors avoid the phrase "the pilots should have...". Instead we are gently encouraged to understand how skilled and professional operators can come to make mistakes in circumstances that are unforgiving of error.
Through the lens of cognitive psychology, the aviation industry becomes a massive human performance laboratory, in which hapless operators are faced with situations and problems produced not by experimenters, but by the complexities of the system of which they are a part. The authors take pains to counter the common presumption that catastrophic accidents must somehow result from extreme acts of villainy or incompetence. In this book, we repeatedly see how accidents often arise from combinations of everyday problems and situations.
By the end of the book, some fascinating patterns begin to emerge. A surprising number of the accidents involved apparently simple slips and lapses. Additionally, the majority of accidents occurred on approach and landing, and most of the accident flights were running late. The failure to go-around from an un-stabilized approach is a common theme in the accident scenarios.
On a minor note, a few more illustrations and diagrams would have added some variety to the text, and more extensive quotations from cockpit voice recordings may have helped. Overall however, the book provides a useful compendium of case studies that will be of value to industry and academia. Airline training personnel in particular will find much that is useful in this book.
An excellent confluence of aviation and psychology.......2007-05-25
Out of approximately 10 million air carrier flights annually in the US, only about 50 involve a major accident. That may not sound like much, but those accidents consist of events like these: a Continental Airlines flight that landed without its landing gear deployed in Houston; an American Airlines flight that suffered loss of control at 16000 ft.; and another American Airlines flight that hit some trees while attempting to land, the culmination of a series of small, individually insignificant errors. These are some of the examples scrutinized in detail, drawn from a large population of accidents in which human error was a major factor. This book makes fascinating reading - providing pilots and aviation professionals with a new perspective on crew error, and the general public with a new way of looking at the whole aviation system and how safety issues are considered.
The authors dissect these accidents in a way that the airline industry has not attempted in great depth before. Rather than stopping at the facts and a conclusion of "crew error", they ask why highly skilled flight crews, with thousands of hours of flying experience, make mistakes and erroneous judgments with horrifying consequences. The common reaction after an accident is that the crew was not sufficiently skilled, otherwise they would not have made the error. The authors start with a different assumption: they assume that the crew was as good as any other crew that could have been chosen, and from that starting point, their illuminating analyses lead them to consider some very interesting psychological and operational factors that underlie these accidents.
To do this, the authors draw on their expertise on how the human brain works (memory systems and decision-making apparatus) and their complementary expertise on aviation and operations. The authors are all affiliated with NASA; two of the them are research psychologists, one of them was a major investigator with the primary transportation investigative arm of the government, the National Transportation & Safety Board, and all of them have extensive experience with aviation safety.
The book covers 19 accidents, devoting a chapter to each. Two additional chapters at the end provide statistics and a summary of the common themes and factors the authors uncover as contributing to these accidents, along with some prescription of possible countermeasures. When an airplane is involved in an accident, the National Transportation & Safety Board performs thorough investigations - these include interviews with the survivors, forensic evidence, the data from the black box, etc. The investigators produce a report that lays out the facts and their judgment of the causes of the accident.
The studies in this book take these reports as a starting point, and go down paths that the NTSB never ventures (their charter does not permit that). Each of the accident chapters is constructed to provide first a factual recount of the event and the NTSB conclusions. From here the authors identify the most significant events leading up to the accident, and for each event in turn, provide an analysis that mixes operational knowledge with cognitive functioning.
This is not a Michael Crichton thriller, but those familiar with aviation will easily be able to follow the details as they are stated in factual, non-judgmental manner, and will see into the deep causes of the events that led up to the final accident. Readers who are already familiar with aviation terminology will find the book easy to read (do you know what "LOFT" and "windshear" mean?). At the end, the very helpful glossary covers both aviation and cognitive psychology terms so that readers of all levels of industry expertise or interest can enjoy this useful study.
The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents.......2007-05-13
It reads like a thesis but is full of great analyses beyond the "official" accident reports. Most aircraft accidents are attributed to "pilot error." Here, the authors dissect the human factors in several accidents and delve into human fallibilities and technical traps which make us all prone to error.
The value of rethinking.......2007-05-04
Air travel has become remarkably safe as a result of advances in equipment systems, operating procedures and training. Each year, flight crews deal skilfully with sub-optimal systems and unexpected situations during the course of around 17 million flights world-wide. Yet airlines operate in a highly competitive market with pressures to deliver unprecedented levels of efficiency, so it is now more important than ever to understand what makes the air transport system vulnerable to failure. Since most aviation accidents have been attributed to deficiencies in the performance of flight crews, it is particularly important to understand what makes pilots vulnerable to error.
In this outstanding and original book, the authors argue that human skill and vulnerability to error are closely linked: errors occur because flight crews are expected to perform tasks at which perfect reliability is not possible - either for humans or machines. The authors show that the presence and interaction of factors contributing to error is probabilistic rather than deterministic. Accidents are rarely caused by a single factor, but rather by the complex interaction of many factors that combine in ways driven largely by chance. The authors argue that small, random variations in the presence and timing of those factors can drastically increase the probability of pilots making errors leading to an accident.
Consequently, it is crucial to understand the nature of vulnerability to error in order to reduce that vulnerability. While it is not always possible to determine exactly why accident crews did what they did, the authors demonstrate that it is possible to understand the types of error to which pilots are vulnerable - and to understand the interplay of various factors contributing to that vulnerability. The central questions posed in this book are: why do highly skilled professional pilots make errors, with consequences that are sometimes fatal to themselves and to their passengers? And how should we understand the role of these errors in accidents in seeking to prevent future accidents? The authors apply scientific knowledge of the nature of skilled performance of humans performing complex tasks to address these questions.
The book reviews the 19 major accidents in US airline operations during the period 1991-2000 in which crew errors played a central role, as defined by the US National Transportation Safety Board (NTSB), based on the NTSB reports and associated documents. While the NTSB must determine the probable cause of each specific accident, the authors take a different approach: would other pilots be vulnerable to making the kinds of errors made by the accident crew and, if so, why? This original approach reveals factors that make all pilots vulnerable to specific types of error in certain situations. In adopting this approach, the authors challenge the assumption that, if expert pilots make errors, this is evidence of their lack of skill, vigilance or conscientiousness. Instead, the authors emphasise the interactions of subtle variations in task demands, incomplete information available to pilots, and the inherent nature of skilled performance. The authors go beyond accident investigation, therefore, to explore the common themes and `deep structure' underlying the accidents.
In addition to the stand-alone accident chapters, the authors provide a statistical summary chapter that extends an earlier study by the NTSB and that reviews accident data for a longer period (1978-2001). In the final chapter, the authors identify the main themes and implications of their study, suggesting specific ways to improve aviation safety. Many issues are raised, including the significance of crew familiarity, crew fatigue, first officer experience levels, unstabilized approaches, plan continuation bias, misleading or absent cues, and monitoring/challenging errors. The authors reframe these airline accidents as `system accidents' resulting from the lack of adequate information provided to crews, the inherent difficulties of assessing ambiguous situations, and the less than extremely conservative guidance given to pilots by the air transport industry.
Overall, this is an excellent and innovative text which reflects the authors' original approach to airline safety. The book is outstanding in its identification of common themes that run deeper than in previous analyses of aviation safety, and the final chapter contains clear, pragmatic guidance to the air transport industry and to researchers. In the final sections of the book, the authors sum up the central challenge faced by the industry in reducing vulnerability to error: pilots should be given more information, better interfaces and clearer decision-making guidance - backed up by prioritising adherence to that guidance over commercial pressures such as on-time performance.
The book will be informative for diverse readers in the air transport industry, including operational staff, researchers, safety analysts, accident investigators, designers of systems and procedures, training providers and students. Given the nature and scope of their study, the authors have focused on the US context, yet their approach could valuably be applied to other parts of the world: a comparable study for Europe, for instance, would be revealing. Their approach could also be extended to other parts of the air transport system, such as air traffic management, where the performance of skilled experts is also implicated in some airline accidents.
The main significance of this book is in its re-framing of the causes of airline accidents: the authors argue that, if we must continue to conceive of airline accidents in terms of deficiency, then that deficiency should be attributed to the overall air transport system. Such an approach can contribute to aviation safety by providing a foundation for improving equipment, training, procedures and organisational policy. In so doing, it is possible to reduce the frequency of `system accidents' and to devise adequate protection against the types of errors to which many, if not all, pilots - as well as many other experts - are vulnerable.
Book Description
The Atomic Chef is an altogether new collection of 20 true stories about technology and design-induced human error by the author of the highly-acclaimed original, Set Phasers on Stun. The 20 stand-alone chapters of this new work describe — with shocking and graphic candor — how technological failures result from the incompatibilities between the way things are designed and the way people actually perceive, think, and act. New technologies will succeed or fail based on our ability to minimize these incompatibilities between the characteristics of people and the characteristics of the things we create and use.
This book is the quintessential `must read' for all those who deal with technology in any fashion. From the frustration of an awkward ATM machine to the threat of accidental, nuclear Armageddon, Casey shows how the same crucial factors come into play told through the very eyes of those people who saw and experienced these things. No student of design, psychology, behavioral science, or technology should be without this book and then again, neither should any intelligent member of society who wants to know what goes on with the successes and failures of modern technology.
Sit ringside to the action where compelling events unfold. The stories in this book will take you to airports and airline cabins, an amusement park, a fertility clinic, a pharmaceutical plant, an emergency dispatch center, the Olympic games, and a bank; to hospitals, spacecraft, ships, and cars. From the coasts of Peru and Monterey, in orbit aboard the International Space Station, the freeways of Southern California and the back roads of France, the battlefields of Afghanistan, and a nuclear fuel plant in Japan — this is The Atomic Chef.
Customer Reviews:
Great product and fast delivery!.......2007-09-16
This product was in perfect shape and I received it in no time! I was very happy with this transaction!
If You are involved in Public Safety, You Need to Read This Book!.......2007-02-14
Fascinating stories on human stupidity, negligence, incompetence and lack of common sense that ends up costing people's lives. Anyone involved with Engineering, Sciences or Maintenance needs to read this book. Actually everyone should read this book to understand human failings and why no one should ever take safety for granted. Every day people die needlessly and this book details how and why.
I really commend the author for bringing these stories to print and hope that it may save some lives.
Brilliantly written.......2006-10-17
This anthology of 20 brilliantly written true stories should be of special interest to anyone dealing with technology management or product development, but it also would be enjoyed by any lay reader. As a well-known expert and writer on human factors engineering and human error, Steven Casey has obviously selected these stories because each subtly educates the reader about the role of the user interface in system failure, but also because each is tremendously interesting.
Although each chapter stands solidly on its own, a few stand prominent in my own mind due to personal interests. "Rhymes and Reasons" is a beautifully written story of musician John Denver's fatal flight in a new aircraft. Although an accomplished pilot, Denver's piloting skills were no match for a confusing set of aircraft controls and displays in his just-purchased home-built plane. The story makes the clearest case possible for the importance of good user interface design and ergonomics, and like all the stories in the book this one is thoroughly researched and referenced.
In addition to aviation and aerospace settings, the stories address transportation, maritime, medical, and various everyday events in contemporary life. Particularly poignant is "Event Horizon," a disturbing accident involving a child and an MRI machine in a New York hospital. In hindsight, the reader understands the procedures and barriers that must be in place when dealing with powerful new technologies like this.
Casey throws some truly hilarious stories in the mix to break up the pattern of predictability inherent in a book on error and disaster, and this approach works well. But, overall, be forewarned: the author is skilled at putting the reader in the "pilot's seat" to experience the confusion, shock, and terror that can occur when technology and human behavior conflict. I highly recommended this book.
The Real Deal.......2006-09-28
I just finished reading "The Atomic Chef" and found it difficult to put down. I simply couldn't resist finding out what unexpected consequence or turn of events was around the next corner.
This is an absolute must read if you are in any way involved with the development of new products or services. Sometimes things don't go as planned despite everyone's best efforts. Like the bumper sticker says, "stuff" happens. This book gets into the stuff to reveal what really happened. The author painstakingly researches and recounts the real story behind mismatches in people and technology.
If you like fairy tale endings this may not be the book for you. However, if you are interested in learning the true details behind real world events, I highly recommend the Atomic Chef. In contrast to more traditional Human Factors books or case studies, the Atomic Chef presents enjoyable and eminently readable accounts of actual events.
Little things can make a big difference, I'd recommend The Atomic Chef's cautionary tales to any student or professional interested in learning more about the relationship between people and technology.
Impressive collection.......2006-07-22
This book is an impressive collection of well written episodes that reflects the author's vast knowledge of the subject of human and design error. I came away with a sobering reminder of the complexity of our interaction with technology and with a much greater understanding of the need for human factors engineering. I would reccomend the book to specialist and nonspecialist alike.
Average customer rating:
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Handbook of Human Factors and Ergonomics in Health Care and Patient Safety (Human Factors and Ergonomics Series) (Human Factors and Ergonomics)
Manufacturer: Lawrence Erlbaum Associates
ProductGroup: Book
Binding: Hardcover
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Human Error
ASIN: 0805848851 |
Book Description
In 1999, the Institute of Medicine published a report exposing the high prevalence of medical error, boosting academic, medical, and human factors interest in this field. The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety presents the most current knowledge on concepts and methods of human factors and ergonomics, and their applications to help improve quality, safety, efficiency, and effectiveness in patient care. This influential book provides specific information on how to analyze medical errors with the fundamental goal to reduce such errors and the harm that potentially ensues.
Editor Pascale Carayon and an impressive group of contributors highlight important issues relevant to healthcare providers and professionals and their employers. They discuss the design of work environment and working conditions to improve satisfaction and well-being, and the reduction of burnout and other ailments often experienced by healthcare providers and professionals. It is a remarkably comprehensive account offering readers invaluable knowledge from individuals who are some of the most respected in the field.
This important handbook should be read by all healthcare and human factors professionals, and is very useful to quality improvement and patient safety specialists in healthcare organizations. It is likewise appropriate for graduate-level courses in nursing and other fields, as well as undergraduate courses in human factors, ergonomics, and engineering.
Customer Reviews:
College Book.......2007-05-13
This book is required for my Masters class ... it arrived as described and in a very timely manner.
An outstanding guide, one that has long been needed........2002-12-18
Just as our transportation system, like most complex systems, has grown ever more sophisticated, so have the means of investigating when those systems suffer failures. For years, a pronouncement of "human error" signaled the end of an accident investigation; now it often marks the beginning. It is no longer sufficient to conclude that an error occurred; investigators must now determine why it occurred and what can be done to prevent a recurrence. Yet surprisingly, there has been little in the training canon to prepare the accident investigator for this central function. That is, until now, because Dr. Barry Strauch has masterfully filled that gap. "Investigating Human Error: Incidents, Accidents, and Complex Systems" is that rarity in the literature of any discipline: a text that is thorough, well-organized and also a pleasure to read. Strauch is clearly at home in both the academic world and the gritty, high-stress environment that surrounds the investigator in the field. Each page of his book is informed by his years of experience as an investigator, an educator and a human factors psychologist. With the systematic, insightful approach presented by Strauch, complex systems are no longer impenetrable to the investigator; human error ceases to be a conundrum. Furthermore, Strauch's audience extends well beyond the ranks of investigators alone. His book will be profoundly appreciated by the people who work in airlines and other complex systems, by those who manage them and by those who analyze and regulate them. In fact, Strauch's work will be a compelling read for anyone who is fascinated and perplexed by humans failing to perform as they should in critical missions.
Superb.......2002-10-12
Dr. Barry Strauch's book is a superbly written and researched account by an investigating expert. He weaves an informative tale that maintains an anecdotal and entertaining tone throughout. Dr. Strauch is, quite simply, a literary wizard. His book is truly a gift to the aviation world. His first-hand account of many infamous accidents combined with his expertise and step by step techniques make this an educational yet interesting read. This reader highly recommends this book to anyone in the field of aviation or any person with an interest in the field. This book is a classic in the vein of "Normal Accidents," Charles Perrow's masterpiece. Five stars.
Product Description
Third Edition Includes more examples of accidents caused by the various types of human error. It suggests to engineers how they might approach this problem, and does so by describing accidents, which at first sight seem to be the result of human error.
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