The Structure of the Book

The book is organised into five parts. The present chapter introduces the subject matter. Chapter 2 offers an inside-out guide to being a mind user. We all know what it feels like to have a mind, but we don't always appreciate that 'feelings-of- knowing' can sometimes be very misleading. There are things you think you know about how your mind works, but don't. And there are things you think you don't know, but actually do. To realise your mind's full potential, you need to understand when these feelings of knowing (or not knowing) are useful and when they are deceptive. I will be discussing these mental processes from a user's perspective: from the inside looking out, not from the outside looking in - hence an inside-out view.

I'm not denying the intimate connection between the mind and the brain. It is just that this book is not about brain scans and neural wiring diagrams. While modern techniques can tell us a great deal about the brain's structure and function, they never wholly capture the moment-to-moment experiences of being a mind user, and none can track all of the subtle interactions between the conscious and automatic control processes. And that is what interests me here.

Part II is concerned with unsafe acts: errors and violations, and how they are perceived by those upon whom they impact. Unsafe behaviour may be less fascinating than heroism, but it is no less important.

Chapter 3 focuses on the nature and varieties of human error. In order to limit the damaging occurrence of errors and improve their chances of detection and recovery, we need to understand something of their cognitive origins and the circumstances likely to promote them. This understanding can translate into 'error wisdom' at the sharp end - what has been termed 'individual mindfulness', to be discussed in Part V.

Chapter 4 deals with rule-related behaviour. I begin by considering the various types of violation, and then discuss the social, emotional and systemic factors that lead people to choose not to comply with rules, regulations and safe operating procedures. However, such acts of non-compliance are not universally bad. They can have beneficial as well as unwanted consequences. This becomes evident when we look in detail at the 12 varieties of rule-related behaviour.

Chapter 5 examines a number of different perceptions of human unsafe acts, of which the two most dominant are the person and the system models. Each has its own theory of how these unsafe acts arise, and how they might be remedied and managed. The person model, asserting that errors originate within the minds of the people concerned, is intuitively appealing and still holds sway in many domains. However, over recent years, the system model has gained increasing ascendancy. This argues that the people on the frontline are not so much the initiators of bad events as the inheritors of long-term system failings. My thesis is that the extremes of both views have their shortcomings. We need to strike a balance between the two.

Part III deals with accidents and their investigation. one fact that lends strong support to the system approach is that similar situations keep provoking the same kinds of unsafe acts in different people. These recurrences, discussed in Chapter 6, indicate that a substantial part of the problem is rooted in error- provoking situations rather than in error-prone people. A primary function of error and incident reporting systems is to identify these 'error traps'. Eliminating them becomes a priority task for error management programmes.

Complex hazardous systems are subject to two kinds of bad event: individual accidents, resulting in limited injury or damage, and organisational accidents that occur relatively infrequently but whose consequences can be both devastating and far- reaching. one of the features that discriminates between these two kinds of adverse event is the degree of protection available against the foreseeable hazards. Whereas individual accidents usually result from the failure of very limited safeguards (or their absence), organisational accidents involve a concatenation of breakdowns among many barriers, safeguards, and controls. It is this combined failure of the many and varied 'defences-in- depth' that characterises the organisational accident and it is this type of event that will be the main concern of this book.

Chapter 7 focuses on two pioneering accident investigations that fundamentally changed the way the human contribution to bad events is regarded. In particular, they spelled out how unsafe acts and latent organisational conditions (resident pathogens) interact to breach the multi-layered system defences. It also traces how the emphases of investigations have shifted from technical and human failures at the sharp end to examining the effects of 'upstream' factors such as organisational processes, safety culture, regulation and even the economic and political climate. It is suggested that perhaps the pendulum has swung too far towards identifying causal factors that are remote in time and place from the local events. This chapter also looks at some of the problems facing accident investigators, and others who seek to make sense of the past. One such problem is the failure to differentiate between conditions and causes, thus falling foul of the counterfactual fallacy

For these and related reasons, it is argued that continual tensions between production and protection lead to resident pathogens being seeded into the system, and this is true for all systems. But such organisational shortcomings are conditions rather than causes. Although they contribute to defensive failures, they are not in themselves the direct causes of accidents. The immediate triggers for such bad events are local circumstances: human and technical failures that add the final ingredients to an accident-in-waiting that may have been lurking in the system for many years. All systems, like human bodies, have resident pathogens. They are universals. It is usually only the proximal factors, immediate in both time and space to the accident, that distinguish between a system suffering a catastrophic breakdown and those in the same sphere of operations that do not.

Up to this point, the book deals mainly with the human as a hazard. In Part IV, we look at the other side of the coin: the human as hero. Eleven stories of heroic recovery are told. They are grouped into four chapters:

• Chapter 8 (training, discipline and leadership) examines two military case studies: the retreat of Wellington's Light Brigade on the Portuguese-Spanish border in 1811; and the retreat of the US 1st Marine Division from the Chosin Reservoir in 1950.

  • • Chapter 9 (sheer unadulterated professionalism) deals with Captain Rostron and the rescue of the Titanic survivors in 1912; the recovery of Apollo 13 in 1970; the Boeing-747 Jakarta incident; the recovery of the BAC 1-11 in 1990; and surgical excellence as directly observed in 1995-96.
  • • Chapter 10 (luck and skill) looks at the near-miraculous escapes by the 'Gimli Glider' on the edge of Lake Winnipeg in 1983 and United 232 at Sioux City in 1989.
  • • Chapter 11 (inspired improvisations) discusses General Gallieni and the 'miracle on the Marne' in 1914; and the saving of Jay Prochnow lost in the South Pacific by Captain Gordon Vette in 1978.
  • • What, if anything, did these heroes have in common? Chapter 12 seeks to identify the principal ingredients of heroic recovery.

Part V (Achieving Resilience) has two chapters. Chapter 13 elaborates on Karl Weick's notion of 'mindfulness'. In its broadest sense this involves intelligent wariness, a respect for the hazards, and being prepared for things to go wrong. Mindfulness can function both at the level of the frontline operators and throughout the organisation as a whole. The former we term 'individual mindfulness' and the latter 'collective mindfulness'. Both are necessary to achieve enhanced systemic resilience. We can't eliminate human and technical failures. And no system can remain untouched by external economic and political forces. But we can hope to improve its chances of surviving these potentially damaging disruptions in its operational fortunes.

The last chapter deals with the search for safety, the broadest part of the book's spectrum. Two models of safety are described: the safety space model and the knotted rubber band model. The former operates at the cultural and organisational levels; the latter has a more tactical focus and deals with keeping some continuous frontline process within safe boundaries. Together, they have implications for re-engineering an existing culture to improve safety and resilience. Or, to put it another way, this concluding chapter is concerned with the practical measures necessary to achieve states of both individual and collective mindfulness.

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