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The Field Guide to Understanding Human Error 2nd Edition

4.5 out of 5 stars 28 customer reviews
ISBN-13: 978-0754648260
ISBN-10: 0754648265
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Product Details

  • Paperback: 252 pages
  • Publisher: CRC Press; 2 edition (June 30, 2006)
  • Language: English
  • ISBN-10: 0754648265
  • ISBN-13: 978-0754648260
  • Product Dimensions: 0.8 x 6.2 x 9 inches
  • Shipping Weight: 15.2 ounces
  • Average Customer Review: 4.5 out of 5 stars  See all reviews (28 customer reviews)
  • Amazon Best Sellers Rank: #329,391 in Books (See Top 100 in Books)

Customer Reviews

Top Customer Reviews

By Mr. Andrew Evans on May 31, 2008
Format: Paperback
Essential reading for any safety investigator. An eye-opening way to transform your investigations by moving from the old-view to the new-view. I've used this book as a 'course book' for a seminar of 25 safety professionals to great effect. Plus there is a good guide to the role of a safety department too.
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We all are extremely good to forecast the past. When this simple principle is applied to human error, it is very easy blaming the human operator.

Dekker tries to put himself in the shoes of that human operator showing why an analysis that does not try to understand an event from that position is useless.

There is a very hard criticism to different kind of positions taken by people that do not make that effort.

If we try to make something as a "winzip on a summary" of the book, I think we could reach these conclusions:

When we have to analyze an event, it should be useful starting with this hipothesis: "People are not usually dumb, people are not usually crazy and people have not usually chosen the day of a big accident to make self-killing." This starting point could be enough to avoid many of the practices fairly critiziced by Dekker.
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Format: Paperback
Mr Dekker's books should be required reading for all accountable executives in high reliability organizations. Over 30 years as a continuous system improvement advocate, I have recently developed a "Recommended Reading" list for those who are new to the field of human factors and system safety. Dekker now as 3 books on that list, with the recent release of "Just Culture."

We live in the information age now; the only way to improve our lot is to share information for the purpose of continual learning. Dekker's approach points the way.
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This book is the perfect introduction to systems thinking when trying to understand accidents, improve safety, and make systems more resilient. The examples are great, and the author's perspective comes through loud and clear. He puts in clear relief the "old way" and "new way" of thinking about error, lays out his case for transitioning to the new way, and does it all clearly and concisely. Great read! I'll be buying extra copies to lend to colleagues.
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Format: Paperback
I agree with some other reviewers that there's a bit too much repetition in this book, and in fact there's considerable repetition across Dekker's numerous books. But they're good books which have substantially shaped my thinking related to safety, and I enjoy reading them because Dekker probes the issues deeply in an engaging and conversational way.

This particular book purports to be a 'field guide', implying that it has a 'how to' orientation. To some extent it does, but it should be clarified that the focus is *understanding* human error, not investigating it or preventing it (and the book challenges the utility of the concept of 'human error'). As such, the main goal of the book appears to be presenting a theoretical framework for thinking about safety which Dekker, as a member of the safety research community, has developed over the past two decades. The core elements of this framework might be summarized as follows:

(1) Many of the systems we deal with are complex, with interactions of both human and physical factors.

(2) Complex systems aren't inherently safe, their natural tendency is to drift towards failure.

(3) We don't see more failures than we do because people, generally being well intentioned, are continually making an effort to cope with the pressures they face to achieve various goals, while simultaneously trying to avoid failures and maintain safety. This usually requires transcending formal rules and procedures in order to adapt to the needs of particular dynamically evolving circumstances. But sometimes these efforts do fall short, cumulatively over time, hence we have some failures.
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Quite an interesting take on accident investigation and understanding human error. The paradigm of the investigator placing themselves "inside the tunnel" to avoid hindsight bias is a powerful metaphor.
Some of the chapters get to be a bit hard going - with lots of restating the basic tenet of Old View vs New View though.
All in all - quite thought provoking and worth a read.
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The book feels too long for the content. By the halfway mark I lost interest because every page seemed to be a enforcement of "human error is where a investigation should start, not where it should end". I was hoping to see more examples on which typical system constructions or set ups cause human error.
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This should be required reading for folks conducting Root Cause analysis.

Avoid the traps of "Old" thinking. Why did the obvious (to us in hindsight) errors occur? Why did those decisions make sense at the time they occurred?

Gain some real insight as to the roots and pervasive nature of human error.
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