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Summary
Summary
Accidents are preventable, but only if they are correctly described and understood. Since the mid-1980s accidents have come to be seen as the consequence of complex interactions rather than simple threads of causes and effects. Yet progress in accident models has not been matched by advances in methods. The author's work in several fields (aviation, power production, traffic safety, healthcare) made it clear that there is a practical need for constructive methods and this book presents the experiences and the state-of-the-art. The focus of the book is on accident prevention rather than accident analysis and unlike other books, has a proactive rather than reactive approach. The emphasis on design rather than analysis is a trend also found in other fields. Features of the book include: -A classification of barrier functions and barrier systems that will enable the reader to appreciate the diversity of barriers and to make informed decisions for system changes. -A perspective on how the understanding of accidents (the accident model) largely determines how the analysis is done and what can be achieved. The book critically assesses three types of accident models (sequential, epidemiological, systemic) and compares their strengths and weaknesses. -A specific accident model that captures the full complexity of systemic accidents. One consequence is that accidents can be prevented through a combination of performance monitoring and barrier functions, rather than through the elimination or encapsulation of causes. -A clearly described methodology for barrier analysis and accident prevention. Written in an accessible style, Barriers and Accident Prevention is designed to provide a stimulating and practical guide for industry professionals familiar with the general ideas of accidents and human error. The book is directed at those involved with accident analysis and system safety, such as managers of safety departments, risk and safety consultants, human factors professionals, and accident investigators. It is applicable to all major application areas such as aviation, ground transportation, maritime, process industries, healthcare and hospitals, communication systems, and service providers.
Author Notes
Erik Hollnagel has been Full Professor of Human-Machine Interaction at Linköping University (S), since 1999. Previously Principal Advisor, OECD Halden Reactor Project, Norway (1995-1999); Technical Director, HRA Ltd., UK (1993-1995); Senior researcher, Department Manager, and later Principal Scientist, Computer Resources International, Denmark (1985-1993). In addition to Coping with Computers in the Cockpit edited with Sidney Dekker, he has written two books on reliability and accidents: Human reliability analysis, Academic Press, 1993; Cognitive Reliability and Error Analysis Method, 1998 and Cognitive Task Design, 2003. He has worked closely with the patient safety programmes in Sweden, training doctors and nurses in risk assessment.
Table of Contents
Preface | p. x |
What is this Book About? | p. xi |
Readership and Outline | p. xiii |
Acknowledgements | p. xvi |
Chapter 1 Accidents and Causes | |
Introduction | p. 1 |
What is an Accident? | p. 3 |
A Little Etymology | p. 4 |
Definition of Accident | p. 5 |
Accidents versus Good Luck | p. 7 |
Accident as Noun and as Verb | p. 8 |
Accidents, Causes and Consequences | p. 10 |
Unwanted Outcomes | p. 10 |
Lack of Unwanted Outcome | p. 13 |
Unexpected Events | p. 13 |
Beyond Design-Base Accidents | p. 15 |
Intended Acts and Unintended Outcomes | p. 16 |
The Grounding of s/s Stockholm | p. 17 |
Accidents, Incidents, and Near Misses | p. 20 |
The Search for Causes | p. 25 |
Facts and Explanations | p. 26 |
The Difference between Explanations and Causes | p. 27 |
From Technological Failure to 'Human Error' | p. 29 |
Causality and Time | p. 31 |
Evolving Concepts of Causes | p. 32 |
A Cynical Definition of Causes | p. 34 |
Chapter 2 Thinking about Accidents | |
Introduction | p. 36 |
The Search for Causes in Science and Philosophy | p. 38 |
The Big Bang | p. 39 |
Causality | p. 41 |
The Need for Accident Models | p. 44 |
Sequential Accident Models | p. 47 |
The Root Cause | p. 51 |
Epidemiological Accident Models | p. 54 |
Performance Deviations | p. 54 |
Environmental Conditions | p. 54 |
Barriers | p. 54 |
Latent Conditions | p. 55 |
Systemic Accident Models | p. 59 |
The Sharp End and the Blunt End | p. 62 |
Consequences of Systemic Models | p. 65 |
Comments to the Models | p. 65 |
Chapter 3 Barrier Functions and Barrier Systems | |
Introduction | p. 68 |
Origin of Barriers | p. 69 |
Barrier Examples | p. 71 |
Getting In and Out of Doors | p. 72 |
Accidents in Sweden | p. 73 |
Barriers and Accidents | p. 76 |
Use and Description of Barriers | p. 78 |
The Prevention of Accidents | p. 79 |
Barriers and MORT | p. 79 |
The Barrier Concept in Risk Analysis | p. 81 |
The Accident Evolution and Barrier (AEB) Model | p. 82 |
Barriers and Latent Failures | p. 83 |
Barriers in Software Systems | p. 84 |
Classification of Barriers | p. 85 |
Classification Based on the Origin of Barrier | p. 85 |
Classification Based on Purpose of Barrier | p. 86 |
Classification Based on Barrier Location | p. 86 |
A Classification of Barrier Systems | p. 87 |
A Classification of Barrier Functions | p. 89 |
Composite Barrier Systems | p. 94 |
Bus Doors Revisited | p. 96 |
Barrier Analysis and Barrier Design | p. 97 |
Barrier Quality | p. 97 |
Physical Barrier Systems | p. 99 |
Functional Barrier Systems | p. 100 |
Symbolic Barrier Systems | p. 101 |
Incorporeal Barrier Systems | p. 102 |
Barriers and Failure Modes | p. 104 |
Other Types of Barriers | p. 106 |
Organisational Barriers | p. 107 |
Chapter 4 Understanding the Role of Barriers in Accidents | |
Introduction | p. 109 |
Representation of Barriers in Accident Analysis | p. 110 |
Fault trees | p. 112 |
Wrong Drug Dispensed | p. 114 |
Event Trees | p. 115 |
Fault Trees and Event Trees Compared | p. 117 |
The AEB Model | p. 118 |
Variation Diagrams | p. 119 |
Representing Barriers in Accident Descriptions | p. 121 |
The Limitation of Graphical Representations | p. 123 |
The Systemic View | p. 124 |
Complexity of Barrier Functions | p. 129 |
Reciprocity | p. 129 |
Barrier Bypass | p. 130 |
Unintended Barriers | p. 132 |
Bi-Directional Barriers | p. 133 |
Barriers and Accident Prevention | p. 135 |
Responding to Accidents | p. 136 |
Chapter 5 A Systemic Accident Model | |
Introduction | p. 140 |
Time and Variability | p. 142 |
The Principle of Efficiency-Thoroughness Trade-Off | p. 144 |
Nominal and Actual Conditions of Work | p. 145 |
The Paradox of Optimal Performance | p. 147 |
The Need for Local Optimisation | p. 149 |
Why Things (Sometimes) go Wrong | p. 150 |
ETTO Rules | p. 152 |
ETTO on the Level of Cognitive Functioning | p. 153 |
ETTO on the Level of Individual Work | p. 154 |
ETTO on the Organisation Level | p. 156 |
ETTO in Practice | p. 156 |
The Sources of Success | p. 159 |
Stochastic Resonance as a Model for Accidents | p. 159 |
Tacoma Narrows Bridge | p. 162 |
London Millennium Bridge | p. 163 |
Stochastic Resonance | p. 164 |
Resonance in Complex Systems | p. 167 |
From Stochastic to Functional Resonance | p. 170 |
Functional Resonance Accident Model (FRAM) | p. 173 |
About FRAM | p. 175 |
Chapter 6 Accident Prevention | |
Introduction | p. 177 |
The Reality of Risks | p. 178 |
Requisite Imagination | p. 181 |
Harnessing Imagination | p. 183 |
Accident Prediction | p. 185 |
Step 1 Identify Essential System Functions | p. 187 |
Step 2 Determine the Potential for Variability | p. 189 |
Common Performance Conditions | p. 190 |
Step 3 Define Functional Resonance Based on Dependencies among Functions | p. 193 |
Finding the Expected Connections | p. 194 |
Finding the Unexpected Connections | p. 196 |
Step 4 Deciding on Countermeasures | p. 199 |
Performance Variability Management | p. 200 |
Detection and Control of Performance Variability | p. 201 |
The Receding Sharp End | p. 205 |
Bibliography | p. 209 |
Author Index | p. 216 |
Subject Index | p. 219 |