The purpose of this book is to explore the human contribution to both the reliability and resilience of complex well-defended systems. The predominant mode of treating this topic is to consider the human as a hazard, a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns.
But there is another perspective, one that has been relatively little studied in its own right, and that is the human as hero, a system element whose adaptations and compensations have brought troubled systems back from the brink of disaster on a significant number of occasions. What, if anything, did these heroes have in common? Can these abilities be 'bottled' and passed on to others?
Insightful, eloquent and extremely accessible, James Reason provides the reader with an essential guide to human behaviour on individual and organisational levels, examining the human from both perspectives:
Part I: Introduction
1. The human contribution: hazard and hero
2. A user's guide to the mind
Part II: Unsafe Acts
3. The nature and varieties of human error
4. The varieties of rule-related behaviour
5. Perceptions of unsafe acts
Part III: Accidents
6. Recurrent accident patterns
7. Significant accident investigations
Part IV: Heroic recoveries
8. Training, discipline and leadership
9. Sheer unadulterated professionalism
10. Luck and skill
11. Inspired improvisation
12. The ingredients of heroic recovery
Part V: Achieving resilience
13. Individual and collective mindfulness
14. In search of safety
The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an extremely valuable and thought-provoking read.