Managing maintenance error a practical guide 1st Edition by James Reason, Alan Hobbs ISBN 978-0754615903 0754615901
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Product details:
ISBN 10: 0754615901
ISBN 13: 978-0754615903
Author: James Reason, Alan Hobbs
Situations and systems are easier to change than the human condition – particularly when people are well-trained and well-motivated, as they usually are in maintenance organisations. This is a down-to-earth practitioner’s guide to managing maintenance error, written in Dr. Reason’s highly readable style. It deals with human risks generally and the special human performance problems arising in maintenance, as well as providing an engineer’s guide for their understanding and the solution. After reviewing the types of error and violation and the conditions that provoke them, the author sets out the broader picture, illustrated by examples of three system failures. Central to the book is a comprehensive review of error management, followed by chapters on:- managing person, the task and the team; – the workplace and the organization; – creating a safe culture; It is then rounded off and brought together, in such a way as to be readily applicable for those who can make it work, to achieve a greater and more consistent level of safety in maintenance activities. The readership will include maintenance engineering staff and safety officers and all those in responsible roles in critical and systems-reliant environments, including transportation, nuclear and conventional power, extractive and other chemical processing and manufacturing industries and medicine.
Table of contents:
1 Human Performance Problems in Maintenance
The bad news
The good news
Removal versus replacement
Commission versus omission errors
Summary
2 The Human Risks
Taking a systems view
Systems with human elements
Human-related disturbances
Each disturbance has a history
Systems build defences against foreseeable disturbances System defences can also fail
The moral issue
Errors are like mosquitoes
Looking ahead
3 The Fundamentals of Human Performance
Psychology meets engineering
A ‘blueprint’ of mental functioning
Limitations of the conscious workspace
Attention
The vigilance decrement
Attention and habit
Control modes and situations
Three performance levels
Stages in acquiring a skill
Fatigue
Stressors
Arousal
Coping with informational overload
Personality types
Biases in thinking and decision making
Summary
4 The Varieties of Error
What is an error?
Skill-based recognition failures, slips and lapses
Rule-based mistakes
Knowledge-based errors
Violations
Violation types
The consequences of maintenance errors
Summary
5 Local Error-provoking Factors
Documentation
Time pressure
Housekeeping and tool control
Coordination and communication
Tools and equipment
Fatigue
Knowledge and experience
Bad procedures
Procedure usage
Personal beliefs: a factor promoting violations
Links between errors and error-provoking conditions
Summary
6 Three System Failures and a Model of Organizational Accidents
Latent conditions and active failures
The Embraer 120 crash: a shift turnover failure
The Clapham Junction rail collision: the defences that faded away
The Piper Alpha explosion: Failures of both the permit-to-work and the shift handover systems
Modelling organizational accidents
Defences
Summary
7 Principles of Error Management
Nothing new
The principles of error management
The management of error management
Summarizing the EM principles
8 Person and Team Measures
Person measures
Team measures
Summary
9 Workplace and Task Measures
Fatigue management
Task frequency
Design
Housekeeping
Spares, tools and equipment
Using procedures to manage omissions
Summary
10 Organizational Measures
How accidents happen: a reminder
Reactive and proactive measures: working together
Reactive outcome measures
Proactive process measures
Identifying gaps in the defences
Summary
11 Safety Culture
What is a safety culture?
Can a safer culture be engineered?
Creating a just culture
Creating a reporting culture
Creating a learning culture
Types of safety culture: the good, the bad and the
average
Summary
12 Making it Happen: The Management of Error Management
Here comes another one
The common features of safety and quality management
systems
Why error management is necessary
More on mindset
In search of resilience
Summary
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