James Reason Å 1 SUMMARYEen skill based rule based and
knowledge basedbased error types and presents a theory of error Other Side of the Hill forms which includereuency gambling and matching While there is little in the way of application knowing the Fox and the Box fundamentals is always a goodirst step I suggest reading Why We Make Mistakes by Joe Hallinan irst as it is a light un read which provides an overview of many of the topics in Human Error Then when you read this book you can draw connections to stories in Hallinan s text which make the psychology easier to understand This one is not as easy to read as regular prose it is a dry scientific text with details of experiments and models It is a good reference if you re researching human errors This is a difficult read unless you re studying HBR Guide to Finance Basics for Managers for your doctorate in sociology or psychology which I am not I picked this book up after reading another one of the author s book on accidents which was aar easier read However I did get the basics on types of human errors and a general overview of the analyses used in the ield which are inconclusive Humans will always make errors We have moved along since this book was irst published 1990 in inding the root causes of accidents in nuclear power and other hazardous industries With modern tech the march continues on I read this book because working in a pharmacy I hoped that having an understanding of the psychological basis of error might be helpful in avoiding itThe book starts with some history In the early twentieth century Freud was pondering on apparent slips and accidents having a basis in the subconscious I suppose according to Freud if someone made a slip in dispensing medication it would be because they #had some deep seated dislike of a patient or harboured unconscious opinions about their treatment Thankfully # some deep seated dislike of a patient or harboured unconscious opinions about their treatment Thankfully views Le Jardin Sur La Glace from the early twentieth century have aged better In 1905 Ernst Mach wrote that knowledge and errorlow The Book of Shaine from the same mental sources only success can tell onerom the other Mach is referring to the Discover Cooking with Lavender fact that certain helpful types of behaviour can also cause problems For example people have the ability to learn skills which involve a high level of automaticacility allowing musicians to play musical instruments typists to type drivers to drive cars all without thinking about the mechanics of every string plucked key pressed or gear changed But this automatic acility so useful in many situations can be a liability when circumstances alter Step rom a manual car into an automatic and you can run into problems when your left Jack the Giant Killer foot wants to press a clutch that isn t there In a pharmacy if you have dispensed hundreds of boxes of a medication in a particular strength there is an openingor error when you come to dispense an unusual strength of that same medicationI suppose an awareness of this kin. Ajor accidents the book spans the disciplinary gulf between psychological theory and those concerned with maintaining the reliabiblity of hazardous technologies Mu. A Day in the Budwig Diet for such a dry subject I learned a lot about the way weorm knowledge skills and how we make mistakes The last ew chapters were very specific to nuclear and industrialerror types and presents a theory of errortypes and presents a theory of error which include reuency gambling and
Applications So Only About 23 Of Theso only about 23 of the were of any use to me I highly recommend it to anyone interested in the subject Fine book on errors
violationsDistinguishing prior intention and intentional action vs nonintentional or involuntaryCognitive Stage Primary Error TypePlanning MistakesStorage LapsesExecution SlipsActivationSpecific activators mental activators reuency of prior useBoundary categories Was there a prior intention to commit this particular violationand violationsDistinguishing prior intention and intentional action vs nonintentional or involuntaryCognitive Stage Primary Error TypePlanning MistakesStorage LapsesExecution SlipsActivationSpecific activators mental
IF NO THEN ERRONEOUS OR UNINTENDEDno then erroneous or unintended If yes then sabotageRoutine violations a natural tendency to take the path of least effort and b a relatively indifferent environment ie one that rarely punishes violation or rewards observanceExceptional violations tasks or circumstances that make violations inevitable no matter how well intentioned the operators might beDistinguishing between errors and violations violations like drinking and driving close Córka Robrojka (Jeżycjada, following disregarding speed limits erroneous behaviorailing to see signs The Neil Simon Collection failing to check mirrors misjudging speed of oncoming vehiclesViolations declined with age errors did notDefences The limited window of accident opportunity personal safety euipment guards preventing direct contact with dangerous materials or moving parts engineering controls such as automatic safety devices and levels of containmentUnsafe acts than just an error or violation one that is committed in the presence of a potential hazards some mass energy or toxicity that if not properly control could cause injury or damageUnintended ActionSlipAttentionalailures Intrusion Omission Reversal Misordering MistimingLapseMemory Slate (Rebel Wayfarers MC, failures Omitting planned items place losingorgetting intentionsIntended ActionMistakeMistake Rule based mistakes knowledge based mistakesViolationRoutine violations exceptional violations acts of sabotageIntelligent decision support systems Technical adviser Training improvements Computerized support systems This book is probably one of the worst reads I have encountered It is the basis of the most awkward workplace incident investigation and analysis methods I have ever used After opening this book I understand why this analysis process is so cumbersome and ineffective Visit the link or related informationhttpwwwasasiorg2004PPTsYoung% A difficult read but worth it to understand human error rom the perspective of the cognitive psychologist Reason is the author of the Swiss Cheese Model which holds that accidents are the result of the layering of latent ailures on top of unsafe acts and local triggers The book also details the difference betw. 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 D of situation does potentially help guard against times when routine brings the possibility of diminished conscious control But Human Error is not the book to go to if you want simple answers First there are those bad outcomes arising EL SUTIL ARTE DE QUE (CASI TODO) TE IMPORTE UNA MIERDA (HARPERCOLLINS) from useful behaviour Then there s the sense that an error is rarely confined to one person When things go wrong it is usually the result of lots of people making many decisions meeting varied circumstances whichinally lead
"down to the "to the individual who makes a blunder the last piece in a malign jigsaw puzzle Then there are the traps in all the means we employ to guard against error automated systems leading to loss of skills in dealing with problems or systems protected by layers of defence tending to soak up hidden deficiencies until there is a sudden ailure Oddly I came away rom this book with a greater acceptance of error even in trying to Hunter Moon (Grazi Kelly find a way to avoid it Error is inevitable and if you make error aorbidden sin then you can never discuss or learn The Diary of Darcy J. Rhone (Darcy Rachel, from things going wrong It is perhaps ironic that Human Error is a highly academic book which leaves nothing to chance in its numbered sections sub sections and sub sub sections It does notlow Concepts have to be nailed down into endless acronyms leaving me 7 Navykov Vysokoeffektivnykh Lyudej floundering amongst SLIMs SLIs THERPs PSFs PIFs and SUs Even the name Three Mile Island gets turned into TMI I did not enjoy wading through this academic acronym code I can t see any problem with calling Three Mile Island by that name as many times as reuiredNevertheless if you can live with the style and accept that you won tind an easy prescription that will make you a accurate less error prone person this is a very interesting book I would recommend it to anyone working in a job where a small slip can have serious conseuences or to anyone making big decisions where small unintended conseuences in those decisions can store up serious problems Lichtenstein for theuture Probably 3 12 stars Some of this book was really interesting I got a bit list in the sections having to do with genetics but or the most part the writer made the scientific understandable I learned about evolution and random selection as well as history of early man I m very interested in exploring the origins of human errors And this book by James Reason seemed liked a good read I was about to travel and I
DIDN T WANT TO BUY At want to buy a or a hardcover book there are severe weight limitati Very detailed analysis of the human components of industrial accidents The material has been around a while but it s still highly applicable to todays world of work The modes of errors GSM theory has been picked up airly recently and has become an important part of many progressive companies Great book The Battle of Resaca for practitionersocused on the human aspects of accident preventio. Ch 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 typ.