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Managing Maintenance Error : A Practical Guide - James Reason

Managing Maintenance Error

A Practical Guide

Paperback Published: 8th May 2003
ISBN: 9780754615910
Number Of Pages: 200

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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.

Industry Reviews

'...very readable and comprehensive book...This book is a valuable tool for maintenance and engineering professionals.' Danny Azavedo, Maintenance Engineering Society of Australia 'Excellently explained and illustrated throughout, this is ideal reading and reference material for the eager, curious and dedicated safety professional.' Occupational Safety and Health Journal, October 2003 'Concepts are clearly explained throughout, rendering this one of the most practitioner-friendly books I have read for some time. This is an important achievement, for in the high-pressure world of maintenance managers, supervisors and workers need to be able to get at and assimilate useful information quickly. ...It is lucid, accessible and logically structured...' Risk Management: An International Journal, 2004 '...written by two world renowned experts, its contents are applicable to all technologically driven industries. The reader will find it rewarding and it will undoubtedly provide a valuable resource for the understanding and investigation of human error contribution to accidents...should be recommended reading for all involved with management, supervision, training and front line duties involving maintenance, repair and overhaul activities.' The Aerospace Professional July 2004 '...a concise book intended for those in the industry who manage, supervise or carry out maintenance activities. Written in a clear style that should be readily grasped by many people in industry...provides a useful, comprehensive and robust overview of the varieties of human error and factors that promote them. The authors offer practical guidance in managing maintenance error in the form of principles for managing the person, team, workplace, task and organizational aspects of maintenance. Although the stated audience for this book is the maintenance community, human factors practitioners will find a good foundation from which to consider maintenance errors.' Ergonomics in Design 2004 'This is an important book with an essentially applied orientation. The intended readers, in practical engineering contexts, may need initial reassurance about the space given to theory, but they will be rewarded by the wealth of down-to-earth examples.' Ergonomics Vol 48, No 8, June 2005 'Representatives from manufacturing and design organizations, academia, and indeed regulatory bodies may pick up this book with considerable given the relative dearth of material in this field.' The International Journal of Aviation Psychology, 14 (4) 'This book has been written by well-respected authors in the field having vast experiences. I find this book to be valuable for maintenance professionals and engineers. It may be of value to safety staff and safety officers as well. It is a delight to read this book.' Journal of Quality and Maintenance Engineering, Vol. 11, no. 4, 2005 'This is a down-to-earth practitioner's guide to managing maintenance error, written in Dr. Reason's highly readable style. This book deals with human risks generally and the special human performance problems arising in maintenance, as well as providing an engineer's guide fro their understanding and the soluttion.' AAvPA

List of Figuresp. ix
List of Tablesp. xi
Prefacep. xiii
Human Performance Problems in Maintenancep. 1
The bad newsp. 1
The good newsp. 3
Removal versus replacementp. 4
Commission versus omission errorsp. 6
Summaryp. 7
The Human Risksp. 9
Taking a systems viewp. 9
Systems with human elementsp. 10
Human-related disturbancesp. 11
Each disturbance has a historyp. 12
Systems build defences against foreseeable disturbancesp. 12
System defences can also failp. 14
The moral issuep. 14
Errors are like mosquitoesp. 16
Looking aheadp. 17
The Fundamentals of Human Performancep. 19
Psychology meets engineeringp. 19
A 'blueprint' of mental functioningp. 20
Limitations of the conscious workspacep. 21
Attentionp. 22
The vigilance decrementp. 24
Attention and habitp. 24
Control modes and situationsp. 25
Three performance levelsp. 27
Stages in acquiring a skillp. 30
Fatiguep. 31
Stressorsp. 32
Arousalp. 33
Coping with informational overloadp. 33
Personality typesp. 34
Biases in thinking and decision makingp. 35
Summaryp. 36
The Varieties of Errorp. 39
What is an error?p. 39
Skill-based recognition failures, slips and lapsesp. 40
Rule-based mistakesp. 49
Knowledge-based errorsp. 51
Violationsp. 53
Violation typesp. 55
The consequences of maintenance errorsp. 59
Summaryp. 60
Local Error-provoking Factorsp. 63
Documentationp. 64
Time pressurep. 65
Housekeeping and tool controlp. 65
Coordination and communicationp. 66
Tools and equipmentp. 67
Fatiguep. 68
Knowledge and experiencep. 70
Bad proceduresp. 70
Procedure usagep. 72
Personal beliefs: a factor promoting violationsp. 73
Links between errors and error-provoking conditionsp. 74
Summaryp. 75
Three System Failures and a Model of Organizational Accidentsp. 77
Latent conditions and active failuresp. 77
The Embraer 120 crash: a shift turnover failurep. 78
The Clapham Junction rail collision: the defences that faded awayp. 82
The Piper Alpha explosion: Failures of both the permit-to-work and the shift handover systemsp. 86
Modelling organizational accidentsp. 89
Defencesp. 91
Summaryp. 93
Principles of Error Managementp. 95
Nothing newp. 95
The principles of error managementp. 96
The management of error managementp. 100
Summarizing the EM principlesp. 101
Person and Team Measuresp. 103
Person measuresp. 103
Team measuresp. 113
Summaryp. 117
Workplace and Task Measuresp. 119
Fatigue managementp. 119
Task frequencyp. 120
Designp. 122
Housekeepingp. 124
Spares, tools and equipmentp. 124
Using procedures to manage omissionsp. 125
Summaryp. 132
Organizational Measuresp. 133
How accidents happen: a reminderp. 133
Reactive and proactive measures: working togetherp. 134
Reactive outcome measuresp. 135
Proactive process measuresp. 138
Identifying gaps in the defencesp. 141
Summaryp. 143
Safety Culturep. 145
What is a safety culture?p. 145
Can a safer culture be engineered?p. 147
Creating a just culturep. 148
Creating a reporting culturep. 151
Creating a learning culturep. 153
Types of safety culture: the good, the bad and the averagep. 155
Summaryp. 156
Making it Happen: The Management of Error Managementp. 159
Here comes another onep. 159
The common features of safety and quality management systemsp. 162
Why error management is necessaryp. 164
More on mindsetp. 165
In search of resiliencep. 166
Summaryp. 174
Indexp. 177
Table of Contents provided by Ingram. All Rights Reserved.

ISBN: 9780754615910
ISBN-10: 075461591X
Audience: Professional
Format: Paperback
Language: English
Number Of Pages: 200
Published: 8th May 2003
Publisher: Taylor & Francis Ltd
Country of Publication: GB
Dimensions (cm): 22.86 x 15.24  x 1.27
Weight (kg): 0.3
Edition Type: New edition

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