Investigating Human Error Incidents, Accidents, and Complex Systems Second Edition Investigating Human Error Incidents, Accidents, and Complex Systems Second Edition Barry Strauch CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2017 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed on acid-free paper International Standard Book Number-13: 978-1-4724-5868-1 (Paperback) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher can- not assume responsibility for the validity of all materials or the consequences of their use. 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Identifiers: LCCN 2016041252| ISBN 9781472458681 (pbk. : acid-free paper) | ISBN 9781472458650 (hardback) | ISBN 9781315589749 (ebook) Subjects: LCSH: System failures (Engineering) | Accident investigation. | Human engineering. | Aircraft accidents--Investigation. | Aeronautics--Human factors. Classification: LCC TA169.5 .S74 2017 | DDC 363.12/065--dc23 LC record available at https://lccn.loc.gov/2016041252 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com This book is dedicated to the memory of Howard B. Brandon, Jr. 1982–2016 Contents Foreword to Second Edition ................................................................................xv Foreword to First Edition ................................................................................... xxi Preface to Second Edition ...............................................................................xxvii Preface to First Edition ..................................................................................... xxix Author ...............................................................................................................xxxiii 1. Introduction .....................................................................................................1 Introduction ......................................................................................................1 The Crash of ValuJet Flight 592 ......................................................................2 Investigating Error ...........................................................................................5 Outline of the Book ..........................................................................................6 References .........................................................................................................8 Section I Errors and Complex Systems 2. Errors, Complex Systems, Accidents, and Investigations .................... 13 Operators and Complex Systems ................................................................. 13 Complex Systems ...................................................................................... 14 Operators .................................................................................................... 15 Normal Accidents and Complex Systems ............................................. 15 Human Error .................................................................................................. 17 Theories of Error ............................................................................................ 17 Freud ........................................................................................................... 18 Heinrich ...................................................................................................... 18 Norman ...................................................................................................... 19 Rasmussen ................................................................................................. 19 Reason .........................................................................................................20 What Is Error .............................................................................................22 Error Taxonomies ......................................................................................23 Incidents, Accidents, and Investigations .................................................... 24 Incidents and Accidents ........................................................................... 24 Process Accidents ......................................................................................25 Legal Definitions .......................................................................................26 Investigations .............................................................................................27 From Antecedent to Error to Accident ........................................................ 31 Assumptions .............................................................................................. 31 General Model of Human Error Investigation......................................32 Antecedents ...............................................................................................34 Antecedents and Errors ............................................................................34 vii viii Contents Summary .........................................................................................................35 References .......................................................................................................36 3. Analyzing the Data ......................................................................................39 Introduction ....................................................................................................39 Investigative Methodology ...........................................................................39 Ex Post Facto Designs ...............................................................................40 Imprecision ................................................................................................ 41 An Illustration ...........................................................................................42 Analysis Objectives ...................................................................................43 Assessing the Quality of the Data ...............................................................43 Internal Consistency .................................................................................43 Sequential Consistency ............................................................................45 Data Value .......................................................................................................46 Relevance ....................................................................................................46 Quantity .....................................................................................................47 Identifying the Errors ....................................................................................47 The Sequence of Occurrences..................................................................47 The Error or Errors ....................................................................................49 Assessing the Relationship of Antecedents to Errors...............................50 Inferring a Relationship ...........................................................................50 Statistical Relationship .............................................................................50 Relating Antecedents to Errors ............................................................... 51 Counterfactual Questions ........................................................................52 Multiple Antecedents ....................................................................................53