Human Error Reduction and Safety Management

Preface to the Third Edition ix Preface to the First Edition xi Introduction xiii Part I. Human Error Human Error---What It Is 3(6) Human Error---What It Does 9(16) Examples 9(1) Reasons to Look at Error 10(2) Categorizing Errors 12(13) Human Error---Causes 25(12) Influences 25(4) The Human-Error Causation Model 29(8) Part II. System-Caused Human Error Management Causes 37(26) Management Safety Systems 42(14) Assessment Criteria 56(3) Logic Diagrams on Error Causes 59(4) Culture Causes 63(18) Culture Definition 65(1) Culture and Safety 66(1) What Sets the Culture 67(1) Catastrophe Causes 67(6) Assessing Culture 73(8) Design Causes 81(14) How Design Causes Error 85(6) How Design Causes Cumulative Trauma Disorders 91(4) Reducing System-Caused Error 95(14) Reducing Management-Caused Error 95(1) Reducing Culture-Caused Error 96(1) Reducing Design-Caused Error 97(2) Ergonomic Systems Analysis 99(1) Task Analysis 100(5) CTD Analysis 105(4) Part III. Overload Causes and Outcomes of Overload 109(16) Overtime, Shift Work, and Other Trends 109(3) Reactions to Overload 112(5) Psychosocial Factors on the Job 117(8) Capacity 125(20) Human Subsystems 125(6) Total Human Subsystem Considerations 131(5) Dealing with Capacity 136(9) Load 145(18) Short-Term Load 145(12) Long-Term Load 157(3) Dealing with Load 160(3) State 163(16) Motivational State 163(11) Attitudinal State 174(1) Arousal State 174(2) Biorhythmic State 176(1) What to Do about State 177(2) Reducing Overload-Caused Errors 179(16) Strategies for Changing the Work Environment 181(1) Strategies for Reducing Overload 182(13) Part IV. Decision to Err Logical Decision to Err 195(18) Reinforcement as a Determinant 196(3) The Peer Group 199(7) Attitudes 206(3) The Boss's Style, Measures, and Priorities 209(2) What to Do to Get Results 211(2) Proneness 213(10) What It Is 213(5) What to Do about It 218(5) Perception of Risk 223(24) Common Sense and Perception 227(3) Attitudes 230(2) Managing Risk 232(5) Force-Field Analysis 237(5) Achieving Change in People 242(5) Reducing Decisions to Err 247(8) Setting Expectations 247(1) Positive Reinforcement 247(8) Part V. Roles Human Error Reduction Concepts 255(18) What Makes It Happen 256(1) Traditional Controls 257(3) Nontraditional Controls 260(13) Line Management Roles 273(32) Upper Management 273(5) Change 278(3) Upper-Management Changes 281(9) Lower-Management 290(4) Lower-Management Tasks 294(8) The Worker Role 302(3) Role of Staff 305(88) The Change Agent and Approaches to Change 310(13) Part VI. Appendixes Appendix A. Stress Tests (Individuals) 323(12) Appendix B. CTD Analysis 335(4) Appendix C. Ergonomic Data 339(16) Appendix D. Behavioral Research 355(30) Appendix E. Major Incidents 385(8) Index 393