ACKNOWLEDGMENTS

This book first came about as a monograph in 1994 commissioned by the Crew Systems Ergonomics Information and Analysis Center of the Human Effectiveness Directorate of the Air Force Research Laboratory. As the original monograph became increasingly difficult to obtain, we received more and more calls from the safety and human systems communities for an updated and readily accessible version. We would like to thank Guy Loft of Ashgate for his encouragement to develop the second edition, and Lore Raes for her unrelenting efforts to help get it into shape.

The ideas in this book have developed from a complex web of interdisciplinary interactions. We are indebted to the pioneers of the New Look behind the label human error – John Senders, Jens Rasmussen, Jim Reason, Neville Moray, and Don Norman for their efforts in the early 1980s to discover a different path. There have been many participants in the various discussions trying to make sense of human error over the last 30 years who have influenced the ideas developed in this volume: Charles Billings, Véronique De Keyser, Baruch Fischhoff, Zvi Lanir, Todd LaPorte, Gene Rochlin, Emilie Roth, Marty Hatlie, John Wreathall, and many others. A special thanks is due Erik Hollnagel. With his vision, he always has been at the ready to rescue us when we become trapped in the bog of human error.

Ultimately, we extend a special thanks to all who work at the sharp end for their efforts and expertise which keeps such complex and hazardous systems working so well so much of the time. We also thank the many sharp-end practitioners who donated their time and expertise to participate in our studies to understand how systems succeed but sometimes fail.