Being Human in Safety-Critical Organisations

 
 
The Stationery Office Ltd (Verlag)
  • 1. Auflage
  • |
  • erschienen am 11. September 2017
  • |
  • 274 Seiten
 
E-Book | PDF mit Adobe-DRM | Systemvoraussetzungen
978-0-11-553544-4 (ISBN)
 
If human error only starts to explain how accidents happen in complex, adaptive systems, what does the rest of the explanation look like? And what can be done as a result? If complex systems are fundamentally different from merely complicated ones, what does this mean for us - the people who have to live and work in them?Through a re-analysis of real events, this book integrates recent thinking from psychology, resilience engineering, complexity theory and cybernetics.Intimidated? Don't be.The result is a clear story of why people do what they do, how they mostly get it right, why they sometimes get it wrong, where safety really comes from, and why and how organisations need to fundamentally change their assumptions about people if they want to become safer.The book is aimed at all safety-critical sectors, including aviation, chemical, defence, healthcare, highways, maritime, nuclear, rail and space. Throughout, the authors - both of whom are organisational psychologists - provide insight and clear practical guidance on how individuals and organisations can achieve greater resilience by acknowledging the true nature of human beings operating in a world of complexity.
  • Englisch
  • London
  • |
  • Großbritannien
978-0-11-553544-4 (9780115535444)
weitere Ausgaben werden ermittelt
  • Being Human in safety-critical organisations
  • Contents
  • List of figures
  • List of tables
  • Preface - Gretchen Haskins
  • Foreword - Sir Alan Massey
  • Foreword - Chris Bailey
  • Foreword - John Adams
  • Foreword - Capt. Yves Vandenborn
  • Acknowledgements
  • 1 About this book: how people create safety, what stops them and what to do about it
  • Being human
  • A new perspective
  • A new framework
  • 2 Being at work: the curiousness of the problems we really face
  • The puzzle of people
  • What do humans actually do?
  • Speedbird 38 - plucked from the jaws of disaster by human agency
  • What was good here?
  • Unintended consequences - what happens when youpoke a system with a stick
  • The curiousness of the problems we really face
  • 3 Being framed: how context makes us blind
  • A question of perspective
  • Hiding in plain sight
  • A nasty surprise
  • The day attention ran out on Emilia Theresa
  • Attention can become too much of a good thing
  • Isn't this just complacency?
  • A tale of two cities
  • The impossibility of a single, objective context
  • The power of shared context
  • The generation of context
  • Figure 3.1 The three main ingredients in our creation of context
  • How is the SUGAR model used in this book?
  • 4 Being sufficient: how much is enough?
  • Absolute must or relative need?
  • Natural sufficiency
  • Everyday behaviour
  • "Safety is paramount"
  • Erik Hollnagel's efficiency-thoroughness trade-off
  • Table 4.1 ETTO rules
  • Figure 4.1 The SUGAR model
  • The Herald of Free Enterprise catastrophe
  • The ship and crew that day
  • The company
  • Table 4.2 Herald of Free Enterprise: investigation highlights and possible SUGAR influences
  • A spoonful of SUGAR
  • Figure 4.2 The traditional view of the contribution of human factors
  • Figure 4.3 A more comprehensive view of the contribution of human factors
  • 5 Being in a state: what does our state do to our sense of safety?
  • Fitness for work
  • Fatigue
  • Tiredness and accidents
  • How does fatigue arise?
  • How does fatigue affect us at work?
  • Stress
  • What is stress?
  • What does stress do to people?
  • How does stress work?
  • The relationship between stress and complex system operations
  • Boredom and complacency
  • Why is boredom boring?
  • Figure 5.1 The Yerkes-Dodson inverted U curve
  • What is complacency?
  • Failure to see the problem
  • Failure to act on the problem
  • Positive states, performance and safety
  • 6 Being in the know - part I: how our senses deceive us
  • What is it to know something?
  • Our senses
  • The sky is blue - isn't it?
  • Seeing things that aren't there
  • You must be hearing things
  • What you see depends on who you are
  • Figure 6.1 How to see your own blind spot
  • We expect a 3D world
  • Figure 6.2 Conflicting expectations
  • Figure 6.3 The eyes don't have it
  • All our senses are in on it
  • Imperfect channels
  • 7 Being in the know - part II: where meaning comes from
  • Sense-making is construction, not reflection
  • Is that why we can't know everything?
  • Where does emotion fit in?
  • The curious case of Phineas Gage
  • Thinking fast and thinking slow
  • When System 1 dominates
  • USS Vincennes - when worlds collide
  • Different understanding, different response121314
  • What does memory actually remember?
  • Cognitive biases - mechanisms for greater efficiency
  • Figure 7.1 Letters
  • Figure 7.2 Numbers
  • A tragic System 1 miscategorisation
  • The curious problem of attention
  • The grounding of Royal Majesty - a case of misplaced attention
  • Figure 7.3 Actual and plotted courses of Royal Majesty
  • 8 Being in the know - part III: why do we do risky things?
  • Risky business
  • Perceiving risk
  • Why is it difficult to understand probability?
  • Why are consequences difficult to see?
  • Why do consequences surprise us as individuals?
  • Bad calibrations
  • Losing control to motorway madness
  • The catastrophic value of punctuality
  • Hoegh Osaka - when familiarity breeds disaster
  • So, what do we know about risk perception?
  • Perceived control
  • Perceived value
  • Perceived familiarity
  • Biases are sensitive to context
  • Why do consequences surprise systems?
  • 9 Being in the know - part IV: how hindsight deceives us
  • Seeing with hindsight
  • The second-to-worst thing that can happen
  • The tragic story of Concorde, Air France 4590
  • An evolutionary perspective
  • 10 Being on target: managing purposes, procrastination, plans and practice
  • Goals in the SUGAR model
  • What gets you out of bed?
  • What is motivation?
  • Where does motivation come from?
  • Deeper levels of motivation
  • Motivational issues in high-risk environments
  • The conflict between efficiency and thoroughness
  • Other motivational conflicts
  • Motivation and values
  • Procrastination
  • Impulses
  • Habits
  • Willpower and self-control
  • Plans, goals and priorities
  • Self-awareness
  • Stages on the road to expertise
  • Novice - student
  • Advanced beginner - new graduate
  • Competence - one to two years in practice
  • Proficiency
  • Expert
  • How do you become an expert?
  • 11 Being together: good teams, wicked groups and the need for diversity
  • Why does teamwork matter?
  • Two examples of good teamwork
  • Good teamwork prevents a VLCC from grounding
  • Good teamwork aboard United Airlines flight 232
  • Bad teamwork aboard USS Vincennes
  • Figure 11.1 The team as a network of dynamic relationships
  • Ten ways good teams create safety
  • A word of caution
  • Taskwork training versus teamwork training
  • How our social nature can create threats
  • Compliance with group norms and organisational drift
  • The bystander effect
  • Groupthink
  • In-groups versus out-groups
  • Diversity is not a political aspiration - it's a practical need
  • A double-edged sword
  • Cultural diversity and culture shock
  • Table 11.1 Hofstede's value dimensions
  • Cultural variation in the workplace
  • Table 11.2 Examples of different cultural preferences in the workplace
  • The problem with diversity
  • The need for diversity
  • Managing diversity
  • Leadership and safety
  • The magic and mystery of social capital
  • Social capital and teams
  • Social capital and trust
  • 12 Being human: how organisations get the opposite of what they want
  • Mere complication
  • The nature of complexity
  • Why do we favour efficiency over thoroughness?
  • The 'brakes' of thoroughness, why they fail and how to understand it when they do
  • A 'just' culture is a means - not an end
  • What is 'accountability', how is it different from 'responsibility' and how can it be made fair?
  • Why do organisations need to care about these qualities?
  • What is resilience?
  • Table 12.1 Ways in which complex systems are vulnerable
  • Measuring resilience
  • Two views of safety
  • The real source of safety
  • 13 Being practical - part I: how can you increase your own resilience?
  • About this chapter
  • Do you have trouble with tiredness?
  • Table 13.1 Fatigue questionnaire
  • Assessing your tiredness
  • Dealing with fatigue
  • Dealing with stress
  • Your experience with stress
  • Table 13.2 Stress questionnaire
  • How to prepare for stress
  • What to do when disaster strikes
  • Dealing with complacency
  • Dealing with boredom
  • Dealing with risk
  • Dealing with your unconscious biases
  • Dealing with motivation
  • Table 13.3 Are you in the right job?
  • Table 13.4 How could your job become more motivating?
  • Dealing with your seniors
  • Dealing with difficult people and difficult conversations
  • Difficult people
  • Difficult conversations
  • Dealing with teamwork
  • Table 13.5 How could you improve your team skills?
  • Table 13.6 How could your team do better?
  • 14 Being practical - part II: how can you increase your organisation's resilience?
  • About this chapter
  • Dealing with fatigue
  • Dealing with stress
  • Reducing stress in the workplace
  • Designing for resilience
  • Selecting for resilience
  • Training for resilience
  • Additional benefits of training to cope with pressure
  • Dealing with motivation
  • Dealing in social capital
  • Dealing with complacency
  • Dealing with boredom
  • Dealing with incidents
  • Mindset Analysis
  • Dealing with prevention
  • Safety indicators
  • Resilience indicators in action - the Teekay initiative
  • Detecting resonance with FRAM
  • Figure 14.1 Structure of a function in a FRAM model
  • Creating a strategy for organisational resilience
  • The need for a unifying strategy
  • 1 - A systems approach
  • 2 - An organic approach
  • Figure 14.2 An organic approach to developing a safety culture based on resilience
  • 3 - A performance approach
  • Figure 14.3 HeliOffshore Safety Performance Model (top level)
  • Safety enablers - the potential for 'big data'
  • SUGAR ingredients
  • Last word
  • 15 References
  • Index

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