Reason, J. T.; Hobbs, Alan

Managing Maintenance Error : A Practical Guide

List of Figures ix List of Tables xi Preface xiii Human Performance Problems in Maintenance 1(8) The bad news 1(2) The good news 3(1) Removal versus replacement 4(2) Commission versus omission errors 6(1) Summary 7(2) The Human Risks 9(10) Taking a systems view 9(1) Systems with human elements 10(1) Human-related disturbances 11(1) Each disturbance has a history 12(1) Systems build defences against foreseeable disturbances 12(2) System defences can also fail 14(1) The moral issue 14(2) Errors are like mosquitoes 16(1) Looking ahead 17(2) The Fundamentals of Human Performance 19(20) Psychology meets engineering 19(1) A 'blueprint' of mental functioning 20(1) Limitations of the conscious workspace 21(1) Attention 22(2) The vigilance decrement 24(1) Attention and habit 24(1) Control modes and situations 25(2) Three performance levels 27(3) Stages in acquiring a skill 30(1) Fatigue 31(1) Stressors 32(1) Arousal 33(1) Coping with informational overload 33(1) Personality types 34(1) Biases in thinking and decision making 35(1) Summary 36(3) The Varieties of Error 39(24) What is an error? 39(1) Skill-based recognition failures, slips and lapses 40(9) Rule-based mistakes 49(2) Knowledge-based errors 51(2) Violations 53(2) Violation types 55(4) The consequences of maintenance errors 59(1) Summary 60(3) Local Error-provoking Factors 63(14) Documentation 64(1) Time pressure 65(1) Housekeeping and tool control 65(1) Coordination and communication 66(1) Tools and equipment 67(1) Fatigue 68(2) Knowledge and experience 70(1) Bad procedures 70(2) Procedure usage 72(1) Personal beliefs: a factor promoting violations 73(1) Links between errors and error-provoking conditions 74(1) Summary 75(2) Three System Failures and a Model of Organizational Accidents 77(18) Latent conditions and active failures 77(1) The Embraer 120 crash: a shift turnover failure 78(4) The Clapham Junction rail collision: the defences that faded away 82(4) The Piper Alpha explosion: Failures of both the permit-to-work and the shift handover systems 86(3) Modelling organizational accidents 89(2) Defences 91(2) Summary 93(2) Principles of Error Management 95(8) Nothing new 95(1) The principles of error management 96(4) The management of error management 100(1) Summarizing the EM principles 101(2) Person and Team Measures 103(16) Person measures 103(10) Team measures 113(4) Summary 117(2) Workplace and Task Measures 119(14) Fatigue management 119(1) Task frequency 120(2) Design 122(2) Housekeeping 124(1) Spares, tools and equipment 124(1) Using procedures to manage omissions 125(7) Summary 132(1) Organizational Measures 133(12) How accidents happen: a reminder 133(1) Reactive and proactive measures: working together 134(1) Reactive outcome measures 135(3) Proactive process measures 138(3) Identifying gaps in the defences 141(2) Summary 143(2) Safety Culture 145(14) What is a safety culture? 145(2) Can a safer culture be engineered? 147(1) Creating a just culture 148(3) Creating a reporting culture 151(2) Creating a learning culture 153(2) Types of safety culture: the good, the bad and the average 155(1) Summary 156(3) Making it Happen: The Management of Error Management 159(18) Here comes another one 159(3) The common features of safety and quality management systems 162(2) Why error management is necessary 164(1) More on mindset 165(1) In search of resilience 166(8) Summary 174(3) Index 177