当面对人为错误问题时,你可能会问“他们为什么不多加注意呢?”他们怎么可能没有注意到呢?”你认为你可以通过告诉人们要更加小心,通过训斥坏人,通过发布新的规则或程序来解决人为错误问题。这些都是“坏苹果理论”(The Bad Apple Theory)的表现形式,即你相信如果没有那些不可靠的人,你的系统基本上是安全的。这种关于人为错误的旧观点已经越来越过时了,它将使你一事无成。相反,新的观点理解人为错误问题实际上是一个组织问题。发现“人为错误”的任何其他名字,或任何其他人为错误,只是你旅程的开始,而不是一个方便的结论。新的观点认识到,系统是安全与其他压力(例如:生产)之间的内在权衡。人们需要通过实践来创造安全,在组织的各个层面。突破了它的成功的前身,理解人为错误的领域指南指导你通过陷阱和旧观点的误解。 It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language. But it also helps you look forward. It suggests how to apply the new view in building your safety department, handling questions about accountability, and constructing meaningful countermeasures. It even helps you in getting your organization to adopt the new view and improve its learning from failure. So if you are faced by a human error problem, abandon the fallacy of a quick fix. Read this book.
当面对人为错误问题时,你可能会问“他们为什么不多加注意呢?”他们怎么可能没有注意到呢?”你认为你可以通过告诉人们要更加小心,通过训斥坏人,通过发布新的规则或程序来解决人为错误问题。这些都是“坏苹果理论”(The Bad Apple Theory)的表现形式,即你相信如果没有那些不可靠的人,你的系统基本上是安全的。这种关于人为错误的旧观点已经越来越过时了,它将使你一事无成。相反,新的观点理解人为错误问题实际上是一个组织问题。发现“人为错误”的任何其他名字,或任何其他人为错误,只是你旅程的开始,而不是一个方便的结论。新的观点认识到,系统是安全与其他压力(例如:生产)之间的内在权衡。人们需要通过实践来创造安全,在组织的各个层面。突破了它的成功的前身,理解人为错误的领域指南指导你通过陷阱和旧观点的误解。 It explains how to avoid the hindsight bias, to zoom out from the people closest in time and place to the mishap, and resist the temptation of counterfactual reasoning and judgmental language. But it also helps you look forward. It suggests how to apply the new view in building your safety department, handling questions about accountability, and constructing meaningful countermeasures. It even helps you in getting your organization to adopt the new view and improve its learning from failure. So if you are faced by a human error problem, abandon the fallacy of a quick fix. Read this book.
公正的文化是一种信任、学习和问责的文化。当事件已经发生时,这一点尤为重要;当事情出了差错。你如何回应相关人员?你怎么做才能把负面影响降到最低,让学习最大化?这是西德尼·德克尔极其成功的《公正文化》的第三版,它提供了恢复性司法的新材料,以及关于为什么你的人可能会违反规则的想法。在大量案例材料的支持下,您将学习安全报告和诚实披露、报应正义文化以及人为错误的刑事定罪。一些人怀疑公正的文化意味着让人们摆脱困境。然而,他们相信,他们需要能够让员工对不良表现负责。在这本新书中,德克尔要求你从不同的角度看待“问责制”。 One is by asking which rule was broken, who did it, whether that behavior crossed some line, and what the appropriate consequences should be. In this retributive sense, an 'account' is something you get people to pay, or settle. But who will draw that line? And is the process fair? Another way to approach accountability after an incident is to ask who was hurt. To ask what their needs are. And to explore whose obligation it is to meet those needs. People involved in causing the incident may well want to participate in meeting those needs. In this restorative sense, an 'account' is something you get people to tell, and others to listen to. Learn to look at accountability in different ways and your impact on restoring trust, learning and a sense of humanity in your organization could be enormous.