INDEX

All index entries shown here correspond to the page numbers within the printed edition only. Within this digital format these page numbers allow for cross referencing only.

accident analysis 212–14

accidents 43–6

accountability 225–6, 230–33

adaptation 191–6

designers 195–6

error 195

adaptation breakdowns 12

adaptive systems 38–9

Air Ontario Flight 1363 accident 52–4

anesthesia 24, 123–5, 231–2

Apollo 13 mission 162–4

artifacts 29, 155–8

Ashby’s Law of Requisite Variety 11

astronomy 4–5

automation 29, 30, 144–54

clumsy 146–53

manual takeover 188–9

over-automation 169–70

Bangalore aviation incident 182–3

barriers 41

blame-free systems 232–3

Boeing 757 landing incident 47–8

brittle tailoring 194–5

buggy knowledge 104–5

bureaucratic culture 49

cascading automated warnings 209–11

case studies

Air Ontario Flight 1363 accident 52–4

anesthesia 123–4, 231–2

Boeing 757 landing incident 47–8

cascading automated warnings 209–10

chemical fire 219–20

coffee makers 62–3

Columbia space shuttle accident 42, 83–7, 129

DC-8 airliner coffee makers 62–3

Eastern Airlines L1011 56–8

Helios Airways B737 80–82

hypotension 113–14

Lexington Comair 5191 accident 70–72

maritime navigation 174–82

medication administration record (MAR) system 65–8

myocardial infarction 101–2

navigation at sea 174–82

risk homeostasis 76

Royal Majesty 174–82

take-off checklists 76–7

Texas A&M University bonfire tragedy 45–6

Webster, Noah 215–17

change

and failure 246–7

side effects of 12–13

chemical fire 219–24

clumsy automation 146–53, 191–6

coffee makers 62–3

cognition 151–3, 155–8

Cognitive Engineering 97–8

cognitive lockup 117–20

cognitive performance 110–11

cognitive systems 32

Columbia space shuttle accident 42, 83–92, 129

complexity 13, 248–9

computers 32–3

context sensitivity 166–7

contextual factors 26

control theory 69–77

coupling 62–5, 144

cross-scale interactions 93

culpability 227–30

data overload 143

DC-8 airliner coffee makers 62–3

decompensation incidents 24

design, of computer-based artifacts 29

distancing through differencing 89, 219–24

domino model 41–6

Eastern Airlines L1011 56–8

emergence 38

energy, risk as 36–8

erroneous actions 20–21

error analysis 212–14

error as information 215–24

error detection 26–9, 187–8

error recovery 26–8

error tolerance 27–8

errors 235–9, see also human error

escalation principle 151–2

failure 243–4, 246–7

failure sensitive strategies 10–11

feedback 187–8, 248–9

fixation 117–20

flight management computers (FMCs) 146–8

food preparation 47

fragmented problem-solving 90

fundamental surprise 47, 215–19

generative culture 49–50

goal conflicts 123–40

going sour scenarios 185–7

Helios Airways B737 80–82

heuristics 108–10

high reliability theory 77–82

hindsight bias 14–16, 33–4, 199–214, 242

human-computer interaction 152

human error 3–5, 19–20, 135–6, 239–41

human expertise, enhancement of 189–90, 247–8

Human Factors 30–31

hypotension 113–16, 136

iceberg model 44

Impact Flow Diagram 155–8

incidents 43–6

inert knowledge 107–8

interactive complexity 62–5

just culture 226–7, 233–5

keyhole property of computer displays 160–62

knowledge 101–4

buggy knowledge 104–5

cognitive performance 110–11

inert 107–8

oversimplifications 108–10

technology change 105–6

knowledge calibration 106–7

latent failures 24–5, 50–59

learning opportunities 224

Lexington Comair 5191 accident 70–72

local rationality 16–17, 137–40

man-made disaster theory 46–50

maritime navigation 174–82

medication administration record (MAR) system 65–8

mental models 104–5

mindset 113–21

mode error 171–85

multiple standards 238

myocardial infarction 101–3

n-tuple bind 137–40

navigation at sea 174–82

neutral practitioner criteria 23, 211–12

normal accident theory 61–9

normative models 23, 207

nuclear power plants 23–4

operating rooms 148–51

operational complexity 187

organizational culture 49–50

outcome failures 21–2, 26–7

outcome knowledge 201–5

over-automation 169–70

oversimplifications 108–10

pathological culture 49

patterns of failure 246

performance 23

performance failures 21–2, 26–7

process assessment 205–11

process defects 22–3

Psychologist’s Fallacy 244

Requisite Variety, Ashby’s Law of 11

resilience 11, 93

Resilience Engineering 36, 38, 83–95

responsibility-authority double binds 130–35

risk, as energy 36–8

risk homeostasis 76

Royal Majesty 174–82

safety 12, 139, 245–6

second stories 241–2

sequence of events model 41–6

situation awareness 116–17

spatial organization 193

standards

for performance assessment 237–8

for process evaluation 206–11

Swiss cheese model 24–5, 50–59

system accidents 61, 69

system failures 28–9, 31–2, 35–9, 199–201

systemic vulnerabilities 244–5

take-off checklists 76–7

technical work, failure 243–4

technology change 105–6

technology, clumsy use of 143–53

technology change 143–5

test flight accident 184–5

Texas A&M University bonfire tragedy 45–6

Three Mile Island accident 215–19

tight coupling 62–5

TMI (Three Mile Island accident) 215–19

training 190

use-centered design 196

virtuality, penalties of 158–69

Webster, Noah 215–17

workload management 193