Cover image for Barriers and accident prevention
Title:
Barriers and accident prevention
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Publication Information:
Aldershot, Hampshire : Ashgate, 2004
ISBN:
9780754643012

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30000010076269 T55 H64 2004 Open Access Book Book
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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

Prefacep. x
What is this Book About?p. xi
Readership and Outlinep. xiii
Acknowledgementsp. xvi
Chapter 1 Accidents and Causes
Introductionp. 1
What is an Accident?p. 3
A Little Etymologyp. 4
Definition of Accidentp. 5
Accidents versus Good Luckp. 7
Accident as Noun and as Verbp. 8
Accidents, Causes and Consequencesp. 10
Unwanted Outcomesp. 10
Lack of Unwanted Outcomep. 13
Unexpected Eventsp. 13
Beyond Design-Base Accidentsp. 15
Intended Acts and Unintended Outcomesp. 16
The Grounding of s/s Stockholmp. 17
Accidents, Incidents, and Near Missesp. 20
The Search for Causesp. 25
Facts and Explanationsp. 26
The Difference between Explanations and Causesp. 27
From Technological Failure to 'Human Error'p. 29
Causality and Timep. 31
Evolving Concepts of Causesp. 32
A Cynical Definition of Causesp. 34
Chapter 2 Thinking about Accidents
Introductionp. 36
The Search for Causes in Science and Philosophyp. 38
The Big Bangp. 39
Causalityp. 41
The Need for Accident Modelsp. 44
Sequential Accident Modelsp. 47
The Root Causep. 51
Epidemiological Accident Modelsp. 54
Performance Deviationsp. 54
Environmental Conditionsp. 54
Barriersp. 54
Latent Conditionsp. 55
Systemic Accident Modelsp. 59
The Sharp End and the Blunt Endp. 62
Consequences of Systemic Modelsp. 65
Comments to the Modelsp. 65
Chapter 3 Barrier Functions and Barrier Systems
Introductionp. 68
Origin of Barriersp. 69
Barrier Examplesp. 71
Getting In and Out of Doorsp. 72
Accidents in Swedenp. 73
Barriers and Accidentsp. 76
Use and Description of Barriersp. 78
The Prevention of Accidentsp. 79
Barriers and MORTp. 79
The Barrier Concept in Risk Analysisp. 81
The Accident Evolution and Barrier (AEB) Modelp. 82
Barriers and Latent Failuresp. 83
Barriers in Software Systemsp. 84
Classification of Barriersp. 85
Classification Based on the Origin of Barrierp. 85
Classification Based on Purpose of Barrierp. 86
Classification Based on Barrier Locationp. 86
A Classification of Barrier Systemsp. 87
A Classification of Barrier Functionsp. 89
Composite Barrier Systemsp. 94
Bus Doors Revisitedp. 96
Barrier Analysis and Barrier Designp. 97
Barrier Qualityp. 97
Physical Barrier Systemsp. 99
Functional Barrier Systemsp. 100
Symbolic Barrier Systemsp. 101
Incorporeal Barrier Systemsp. 102
Barriers and Failure Modesp. 104
Other Types of Barriersp. 106
Organisational Barriersp. 107
Chapter 4 Understanding the Role of Barriers in Accidents
Introductionp. 109
Representation of Barriers in Accident Analysisp. 110
Fault treesp. 112
Wrong Drug Dispensedp. 114
Event Treesp. 115
Fault Trees and Event Trees Comparedp. 117
The AEB Modelp. 118
Variation Diagramsp. 119
Representing Barriers in Accident Descriptionsp. 121
The Limitation of Graphical Representationsp. 123
The Systemic Viewp. 124
Complexity of Barrier Functionsp. 129
Reciprocityp. 129
Barrier Bypassp. 130
Unintended Barriersp. 132
Bi-Directional Barriersp. 133
Barriers and Accident Preventionp. 135
Responding to Accidentsp. 136
Chapter 5 A Systemic Accident Model
Introductionp. 140
Time and Variabilityp. 142
The Principle of Efficiency-Thoroughness Trade-Offp. 144
Nominal and Actual Conditions of Workp. 145
The Paradox of Optimal Performancep. 147
The Need for Local Optimisationp. 149
Why Things (Sometimes) go Wrongp. 150
ETTO Rulesp. 152
ETTO on the Level of Cognitive Functioningp. 153
ETTO on the Level of Individual Workp. 154
ETTO on the Organisation Levelp. 156
ETTO in Practicep. 156
The Sources of Successp. 159
Stochastic Resonance as a Model for Accidentsp. 159
Tacoma Narrows Bridgep. 162
London Millennium Bridgep. 163
Stochastic Resonancep. 164
Resonance in Complex Systemsp. 167
From Stochastic to Functional Resonancep. 170
Functional Resonance Accident Model (FRAM)p. 173
About FRAMp. 175
Chapter 6 Accident Prevention
Introductionp. 177
The Reality of Risksp. 178
Requisite Imaginationp. 181
Harnessing Imaginationp. 183
Accident Predictionp. 185
Step 1 Identify Essential System Functionsp. 187
Step 2 Determine the Potential for Variabilityp. 189
Common Performance Conditionsp. 190
Step 3 Define Functional Resonance Based on Dependencies among Functionsp. 193
Finding the Expected Connectionsp. 194
Finding the Unexpected Connectionsp. 196
Step 4 Deciding on Countermeasuresp. 199
Performance Variability Managementp. 200
Detection and Control of Performance Variabilityp. 201
The Receding Sharp Endp. 205
Bibliographyp. 209
Author Indexp. 216
Subject Indexp. 219