Category Archives: Human Factors

Taking Human Factors to the top of the NHS

Posted by Luigi Fort, Senior Marketing Executive

The Clinical Human Factors Group are taking the human factors message to top-level NHS management at their Safety Science & Solutions conference next week (Birmingham, UK, 12 March 2014). This is particularly timely bearing in mind the National Quality Board’s recent Concordat which aims to embed Human Factors principles and practices into the healthcare system.

The conference will enable Chairs, Chief Executives, Executive and Non-Executive Directors, Chief Operating Officers, Directors of Nursing, Medical Directors and Divisional Managers, Lead Clinicians to gain insights that will positively impact their role in promoting safety, quality and productivity in healthcare.

Ashgate publishes a range of books relating to Human Factors in Healthcare and Patient Safety. Why not take a look on our website?

James Reason’s new book “A Life in Error: from little slips to big disasters”

‘This book is like a personal and intimate trip through the ideas that pioneered human error and industrial safety. It goes into day-to-day experience of errors, contains testimonials and anecdotal information, and widens to system safety. Everything seems to have been said on the topic, and yet the book puts the matter differently in a manner that is true, full and in plain, jargon-free language. I love this book.’    René Amalberti, Haute Autorité de Santé, France

‘Reason’s new book is a master class on human error: a concise tour of his career explaining how mistakes can occur. It is a pleasure to accompany him while he presents his favourite and often funny accounts of fallibility, tempered with insights on the resulting risks and how they can be mitigated.’   Rhona Flin, University of Aberdeen, UK

From James Reason’s introductory note to his new book A Life in Error:

A Life in ErrorThis short book covers the main way stations on my 40-year journey in pursuit of the nature and varieties of human error. Inevitably they represent a very personal perspective, but I have also sought to include contrary opinions.

The journey, as at this point, begins with a bizarre, absent-minded action slip committed by me in the early 1970s—putting cat food into the teapot— and continues until the present with a variety of major accidents that have shaped my thinking about unsafe acts and latent conditions.

The original focus of this enquiry was individual cognitive psychology, but over the years the scope has gradually widened to embrace social, organizational and systemic issues. For the most part, my interest here is more on the journey than on the details of each waypoint—though there will be some exceptions. There are two reasons for this. First, many of the waypoints have been covered in previous Ashgate books. Second, I want to focus on the factors either in my head or in the world that prompted the next step in the journey.

This book is written for all those who have an interest in human factors and their interactions with the workings of technological systems whose occasional breakdowns can cause serious damage to people, assets and the environment. This is a large and diverse group whose number, I hope, includes students, academics and safety professionals of all kinds—and has lately included a growing number of health carers. Where possible, I have tried to make clear the thinking and—if you’ll excuse the unavoidable pun—the reasoning that contributed to the models, metaphors, taxonomies and practices that have influenced the course of this journey.

This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. A Life in Error charts the development of his seminal and hugely influential work from its original focus into individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues. The voyage recounted is both hugely entertaining and educational, imparting a real sense of how James Reason’s ground-breaking theories changed the way we think about human error, and why he is held in such esteem around the world wherever humans interact with technological systems.

About the Author: James Reason has written books on motion sickness, absent-mindedness, human error, aviation human factors, managing the risks of organizational accidents, managing maintenance errors, and the human contribution: unsafe acts, accidents and heroic recoveries. He has worked in a wide variety of hazardous industries, though patient safety is now his primary concern. In 2003, he was awarded an honorary DSc by the University of Aberdeen. He is a Fellow of the British Psychological Society, the Royal Aeronautical Society, the British Academy and the Royal College of General Practitioners. He received a CBE in 2003 for his services to reducing the risks in health care. In 2010, he received an Award for Distinguished Service from the Royal Society for the Prevention of Accidents, and in 2011 was elected an honorary fellow of the Safety and Reliability Society.

‘This book is an authoritative reminder of the journey to gain acceptance of human error as intrinsic to open systems operations as we enjoy it today, portrayed by the witty pen of one of its topmost trailblazers. I thoroughly enjoyed the book, and found the segment on organizational accidents a particular gem.’   Daniel E. Maurino, formerly Coordinator of the Flight Safety and Human Factors Study Programme, International Civil Aviation Organization (ICAO)

‘A fascinating personal and intellectual journey showing the evolution of both James Reason’s personal approach and also the broader history of thinking on error and safety. He has a unique gift for making complex ideas accessible within an absorbing and lucid narrative. And all leavened with wonderful examples of human error and some great stories.’   Charles Vincent, Imperial College London, UK

 ‘Each chapter of this book tells a story where Reason personally confronted a puzzle about accidents, human performance, or organizational decisions. Together the stories build a comprehensive picture of how safety is created but sometime undermined.’   David D. Woods, Ohio State University, USA

‘In this delightful memoir, Jim Reason provides an amazingly comprehensive and understandable explanation of how and why individuals and organizations make mistakes and what to do about it. A valuable review for experts and a perfect introduction for beginners.’   Lucian Leape, Harvard University, USA

More information about A Life in Error: From little slips to big disasters

When selecting a pilot – how do we choose the ‘Right Stuff’?

Posted by Luigi Fort, Senior Marketing Executive

How do we choose the ‘Right Stuff’?

From the early years of aviation here are a couple of examples of what to look for when choosing an aviator…

In 1914: “he must possess an unusual amount of dare-devil spirit” (Dockeray and Isaacs 1921).

The US War Department in 1941: “eliminate all the mental and nervous weaklings including temperamental and personality handicapped individuals such as eccentrics, disturbers, irritable, unsocial, peculiar, gossipy, arrogant, and other mental twists types, all unsuited to aviation.

They are taken from ‘A History of Aeromedical Psychology’ (Tatana M. Olsen, Mathew McCauley and Carrie H. Kennedy), the opening chapter of ‘Aeromedical Psychology’, the new Ashgate book edited by Carrie H. Kennedy, University of Virginia, USA and Gary G. Kay, Cognitive Research Corporation, USA.

Aeromedical PsychologyHow has the science and practice of pilot selection progressed since those times?

Kennedy and Gray provide a guide to aeromedical psychology and the training and selection process.

The Human Factors of Simulation and Assessment series – a call for proposals

Advances in lower-cost technologies are supporting worldwide growth in the use of simulation and naturalistic performance assessment methods for research, training and operational purposes in domains such as road, rail, aviation, mining and healthcare.

This has not been accompanied by a similar growth in the expertise required to develop and use such systems for evaluating human performance. Whether for research or practitioner purposes, many of the challenges in assessing operator performance, both using simulation and in natural environments, are common.

What performance measures should be used?

What technology can support the collection of these measures across the different designs?

How can other methods and performance measures be integrated to complement objective data?

How should behaviours be coded and the performance standards measured and defined?

How can these approaches be used to support product development and training?

How can performance within these complex systems be validated?

This series addresses a shortfall in knowledge and expertise by providing a unique and dedicated forum for researchers and experienced users of simulation and field-based assessment methods to share practical experiences and knowledge in sufficient depth to facilitate delivery of practical guidance.

Series EditorsMichael Lenné, Monash University Accident Research Centre, Melbourne, Australia and Mark Young, School of Engineering and Design, Brunel University, London, UK.

We are actively commissioning new books for this series. If you have a proposal that you feel is appropriate, please contact the Publisher, Guy Loft.

It seems ironic that patients and first responders should suffer injuries en route to treatment

Posted by Luigi Fort, Senior Marketing Executive

‘It seems ironic that patients and first responders should suffer injuries en route to treatment.’

So says (the late) Robert L. Helmreich in the foreword to the new book, Safety and Quality in Medical Transport Systems. He continues:

‘I became aware of the pressure to take risks while transporting patients when I was asked by an organization concerned about its accident rate to analyze causal factors in MedEvac helicopter crashes. Analysis of accidents revealed contributing pressures, including the severity of injury and the youth of the patient as well as weather, night operations, and obstructions to flight.’

To counter such pressures it is essential to develop the right kind of culture within the organizations that provide this vital service. CAMTS (The Commission on Acccreditation of Medical Transport Systems) recognize this and have brought together this reference book to support such organizations in providing the necessary culture. This is an environment that supports risk assessment, accountability, professionalism and organizational dynamics.

Safety and Quality in Medical Transport SystemsSafety and Quality in Medical Transport Systems: Creating an Effective Culture is edited by John W. Overton, Jr. and Eileen Frazer, Commission on Accreditation of Medical Transport Systems, USA

Contributors: Ralph N. Rogers; K. Scott Griffith; Terry L. von Thaden; Clive Adams; Nadine Levick; Kimberly Turner; Bruce A. Tesmer; Robin Graham; Terry Palmer; Roger Coleman; Gregory H. Botz; John W. Crommett; Melissa M. Mallis; John W. Overton Jr; Laurie Shiparski; Philip D. Authier; Eileen Frazer; Donna York Clark; Kate Moore; David F.E. Stuhlmiller; Jacqueline Stocking; Jennifer Hardcastle; Sandra Kinkade Hutton; Patricia Corbett; Dawn M. Mancuso; Kenneth P. Neubauer; David P. Thomson.

Rhona Flin and Sidney Dekker are among the keynote speakers at the 10th Australian Aviation Psychology Association International Symposium later this month

‘Next Generation Safety’ is the conference theme at the AAvPA (Australian Aviation Psychology Association) International Symposium, taking place in Manly, Australia, 19-22 November 2012.

Among the keynote speakers are Rhona Flin, co-author of Safety at the Sharp End, and Sidney Dekker, whose Second Edition of Just Culture was published in June 2012.

Ashgate will be displaying an extensive selection of books, so if you’re at the conference do come along and take a look. If you’re not able to attend, you can always browse the Human Factors pages on our website…

Ashgate at the Building Fatigue Management into Safety Systems conference

Ashgate are a sponsor and exhibitor at the Building Fatigue Management into Safety Systems conference organised by the Royal Aeronautical Society’s Human Factors and Operations Training Group, 30 October, 2012, Crawley, UK. We are particularly pleased to support the Helen Muir Award which will be presented at the event.

At the conference Captain Daniel Maurino will introduce the SMS concept and its relationship to Human Factors. He is a series editor for Ashgate Studies in Human Factors for Flight Operations.

Human Factors in Defence series – a call for proposals

We are actively seeking proposals for our Human Factors in Defence series.

The series is edited by Don Harris (HFI Solutions Ltd); Neville Stanton (University of Southampton) and Eduardo Salas, University of Central Florida.

Books in the series:

Designing Soldier SystemsPamela Savage-Knepshield, John Martin, John Lockett III and Laurel Allender (December 2012)

The Human Factors of FratricideLaura A. Rafferty, Neville A. Stanton and Guy H. Walker

Trust in Military TeamsNeville A. Stanton

Human-Robot Interactions in Future Military OperationsMichael Barnes and Florian Jentsch

Neurocognitive and Physiological Factors During High-Tempo OperationsSteven Kornguth, Rebecca Steinberg and Michael D. Matthews

Command and Control: The Sociotechnical PerspectiveGuy H. Walker, Neville A. Stanton, Paul M. Salmon and Daniel P. Jenkins

Human Factors Issues in Combat IdentificationDee H. Andrews, Robert P. Herz and Mark B. Wolf

Distributed Situation AwarenessPaul M. Salmon, Neville A. Stanton, Guy H. Walker and Daniel P. Jenkins

Digitising Command and ControlNeville A. Stanton, Daniel P. Jenkins, Paul M. Salmon, Guy H. Walker, Kirsten M. A. Revell and Laura Rafferty

Human Factors for Naval Marine Vehicle Design and OperationJonathan M. Ross

Cognitive Work Analysis: Coping with ComplexityDaniel P. Jenkins, Neville A. Stanton, Paul M. Salmon and Guy H. Walker

Macrocognition in TeamsMichael P. Letsky, Norman W. Warner, Stephen M. Fiore and C.A.P. Smith

Modelling Command and ControlNeville A. Stanton, Chris Baber and Don Harris

Performance Under StressPeter A. Hancock and James L. Szalma

Human factors is key to enabling today’s armed forces to implement their vision to “produce battle-winning people and equipment that are fit for the challenge of today, ready for the tasks of tomorrow and capable of building for the future” (source: UK MoD).

Modern armed forces fulfil a wider variety of roles than ever before.  In addition to defending sovereign territory and prosecuting armed conflicts, military personnel are engaged in homeland defence and in undertaking peacekeeping operations and delivering humanitarian aid right across the world.

This requires top class personnel, trained to the highest standards in the use of first class equipment.  The military has long recognised that good human factors is essential if these aims are to be achieved.

The defence sector is by far and away the largest employer of human factors personnel across the globe and is the largest funder of basic and applied research.  Much of this research is applicable to a wide audience, not just the military; this series aims to give readers access to some of this high quality work.

Ashgate’s Human Factors in Defence series publishes specially commissioned books from internationally recognised experts in the field. They provide in-depth, authoritative accounts of key human factors issues being addressed by the defence industry across the world.

We are actively commissioning new books within this area. If you have a proposal that you feel is appropriate to the series, please contact the Publisher, Guy Loft.

The second edition of Sidney Dekker’s Just Culture: Balancing Safety and Accountability

Posted by Luigi Fort, Senior Marketing Executive, Aviation and Human Factors

Building on the enormous success of the 2007 original, Dekker revises, enhances and expands his view of just culture for a second edition, additionally tackling the key issue of how justice is created inside of organizations. The goal remains the same: to create an environment where learning and accountability are fairly and constructively balanced.

The First Edition of Sidney Dekker’s Just Culture brought accident accountability and criminalization to a broader audience. It made people question, perhaps for the first time, the nature of personal culpability when organizational accidents occur.

Having raised this awareness the author then discovered that while many organizations saw the fairness and value of creating a just culture they really struggled when it came to developing it: What should they do? How should they and their managers respond to incidents, errors, failures that happen on their watch?

In this Second Edition, Dekker expands his view of just culture, additionally tackling the key issue of how justice is created inside organizations. The new book is structured quite differently.  Chapter One asks, ‘what is the right thing to do?’ – the basic moral question underpinning the issue.  Ensuing chapters demonstrate how determining the ‘right thing’ really depends on one’s viewpoint, and that there is not one ‘true story’ but several. This naturally leads into the key issue of how justice is established inside organizations and the practical efforts needed to sustain it. The following chapters place just culture and criminalization in a societal context. Finally, the author reflects upon why we tend to blame individual people for systemic failures when in fact we bear collective responsibility.

The changes to the text allow the author to explain the core elements of a just culture which he delineated so successfully in the First Edition and to explain how his original ideas have evolved. Dekker also introduces new material on ethics and on caring for the’ second victim’ (the professional at the centre of the incident). Consequently, we have a natural evolution of the author’s ideas. Those familiar with the earlier book and those for whom a just culture is still an aspiration will find much wisdom and practical advice here.

Contents

Preface
Prologue: A nurse’s error became a crime

  1. What is the right thing to do?
  2. You have nothing to fear if you’ve done nothing wrong
  3. Between culpable and blameless
  4. Are all mistakes equal?
  5. Report, disclose, protect learn
  6. A just culture is your organization
  7. The criminalization of human error
  8. Is criminalization bad for safety?
  9. Without prosecutors there would be no crime
  10. Three questions for your just culture
  11. Why do we blame?

Epilogue
Index

About the author: Sidney Dekker is Professor of Humanities at Griffith University in Brisbane, Australia. Educated as a psychologist in the Netherlands, he gained his Ph.D. in Cognitive Systems Engineering from The Ohio State University, USA. He has lived and worked in Sweden, England, Singapore, New Zealand, and the Netherlands. The author of several best-selling books on system failure and human error, Sidney has been flying the Boeing 737NG part-time as an airline pilot.

What people are saying about the Second Edition:

‘Thought-provoking, erudite, and analytical, but very readable, Sidney Dekker uses many practical examples from diverse safety-critical domains and provides a framework for managing this issue. A ‘must-read’ for anyone interested in safety improvement, but also, one hopes, for politicians, law-makers and the judiciary.’    Dr Tom Hugh, MDA National Insurance Ltd, Sydney, Australia

‘With surgical precision Sidney Dekker lays bare the core elements of a just culture. He convincingly explains how this desired outcome arises from a combination of accountability and (organisational) learning. The real-life cases in the book serve to drive his arguments home in a way that will be easily recognised and understood by practitioners in safety-critical industries, and hopefully also by rule makers and lawyers.’   Bert Ruitenberg, IFATCA Human Factors Specialist

‘Just Culture is essential reading for airline managers at all levels to both understand the endless conflicts that staff face trying to deliver the almost undeliverable and to reconcile accountability for failure with learning from that failure. A soul searching and compelling read.’    Geoffrey Thomas, Air Transport World

More information about Just Culture: Balancing Safety and Accountability 

Does flying lead to loose talk?

Posted by Luigi Fort, Senior Marketing Executive, Aviation and Human Factors

A recent extensive article in the New York Times investigated the propensity for business travellers on commercial flights to disclose information better kept within the confines of the office. Is this owing to carelessness, ignorance of the risks or perhaps something to do with the passenger cabin environment?

In the article, Rob Bor, Ashgate author of Passenger Behaviour, suggests that the emotional and physical strains on passengers makes them susceptible to being indiscrete. He says: “Being at 35,000 feet for more than two hours is going to make you mildly hypoxic, and slightly less oxygen will make you euphoric or may give slightly poorer judgment.”