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Investigating Human Error


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Table of Contents


Chapter One: Introduction

Part I Errors and Complex Systems Chapter Two: Errors, Complex Systems, Accidents, and Investigations Chapter Three: Analyzing the Data Chapter Four: Equipment Part II: Antecedents Chapter Five: The Operator Chapter Six: The Company Chapter Seven: The regulator Chapter Eight: Culture Chapter Nine: Operator Teams Part III: Sources of Data Chapter Ten: Electronic Data Chapter Eleven: Interviews Chapter Twelve: Written Documentation Part IV: Issues Chapter Thirteen: Maintenance and Inspection Chapter Fourteen: Situation Awareness and Decision Making Chapter Fifteen: Automation Chapter Sixteen: Case Study Chapter Seventeen: Final Thoughts References

About the Author

Barry Strauch has lectured and taught human factors, accident investigation techniques, and human error to accident investigators, graduate students, and government and industry officials throughout the world. He is an adjunct faculty member of the psychology department of George Mason University in Fairfax, Virginia. He has been with the National Transportation Safety Board for more than 30 years as a human performance investigator, major aircraft accident investigator in charge, chief of the human performance division and, currently, National Resource Specialist - Human Factors. He has investigated accidents in all major transportation modes, involving vehicles ranging from passenger trains, to Boeing 747s, to nuclear attack submarines. He earned a PhD in educational psychology from the Pennsylvania State University and holds a commercial pilot certificate, with an instrument aeroplane rating.


"This is an extremely important book, one that literally can save lives. For decades, I've argued that blaming an accident was on "human error" is not helpful. It is necessary to understand the root causes (invariably plural) and fix those, otherwise the errors continue. Often the fault lies in design, either of the system or the procedures, but there are a multitude of potential underlying, causes. Barry Strauch's book discusses these issues and provides detailed, valuable guidelines for investigating incidents with the goal, not of finding blame, but of preventing future recurrence."
-Don Norman, University of California, San Diego Design Lab
Author of "Design of Everyday Things"

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