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The human contribution unsafe acts, accidents and heroic recoveries


The Human Contribution: Hazard and HeroIntroductionThe Structure of the BookAbout the BookA Mind User's GuideTip-of-the-Tongue StateThe Conscious and the Automatic Modes of ControlThree Levels of PerformanceInteracting with the Long-term Knowledge BaseIntentions and the Retrieval CycleConcurrent ProcessingThe Relationship Between Memory and Attention: The Blob-and- the-Board ModelSumming UpThe Nature and Varieties of Human ErrorDefining and Classifying ErrorError MythsSlips and LapsesRule-based MistakesKnowledge-based MistakesConclusion: A General RuleViolations and the Varieties of Rule-related BehaviourChernobyl and ZeebruggeViolations Considered as Unsafe ActsWho is Most Likely to Violate?Why Do People Violate Safety Rules?The Mental 'Economics' of ViolatingBad ProceduresProcedure-usageTesting Two Models of Violating BehaviourThe Varieties of Rule-related BehaviourGreat ImprovisersEnd PiecePerceptions of Unsafe ActsThe Plague ModelThe Person ModelThe Legal ModelThe System PerspectivePerson and System Models: Getting the Balance RightError Traps and Recurrent AccidentsAccident-proneness: A Quick SurveyEveryday Error TrapsRecurrent Accident PatternsThe Elements of Recurrent ScenariosCultural DriversConclusionSignificant Accident InvestigationsProblems with the PastChanges in Accident InvestigationThe Mahon and Moshansky reportsHas the Pendulum Swung Too Far?Conditions and CausesCounterfactual FallacyThe Current ViewTraining, Discipline and LeadershipThe Light Division's Retreat at Fuentes de Onoro (1811)The Withdrawal of the 1st Marine Division from Chosin Reservoir (1950)Concluding RemarksSheer Unadulterated ProfessionalismCaptain Rostron and the Rescue of the Titanic Survivors (1912)Saving Apollo 13 (1970)British Airways Flight 09 (1982)The BAC 1-11 incident (1990)Surgical Excellence (1995-97)Major and Minor EventsConcluding RemarksSkill and LuckThe Gimli GliderCaptain Al Haynes and United 232Final WordInspired ImprovisationsGeneral Gallieni and the Paris taxisCaptain Gordon Vette and the Rescue of Jay ProchnowConclusionThe Ingredients of Heroic RecoveryCoping with Expected HazardsCoping with Unlikely but Possible HazardsGeneric QualitiesConclusionIndividual and Collective MindfulnessConsistency versus VariabilityA Dynamic Non-EventCollective MindfulnessIndividual MindfulnessHow the buckets might be 'read' by junior staff working aloneAspects of ResilienceForesight Training at the UK National Patient Safety AgencyOrganisational SupportLooking Towards the FutureMindfulness and ResilienceIn Search of SafetyIntroductionWhat Does the Term 'Safety' Mean?The Two Faces of SafetyThe 'Safety Space' ModelWhat Does a Resilient System Look Like?The Knotted Rubber Band ModelDefining the Nature of Positive SafetyFinal Words
 
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