Provides new insights into the multiple and dynamic trajectories of both near misses and mistakes in complex work environments, based on actual case examples. It also studies the interactions between various activity systems or work practices (design, maintenance, incident investigation, regulation, operation) and their consequences for operational performance. The role of rules and regulations is explored, considering the consequences of deviations and the limitations of enforced compliance. Further, the book explains how to search for, think about and act on information about vulnerability, near misses and mistakes in a way that emphasizes accountability in ways that are not punitive but instead responsible, innovative and provide opportunities for learning.
Writing from different disciplines and theoretical perspectives, the contributors analyse working in risky environments which include air traffic control, offshore mining, chemical plants, neo-natal intensive care units, ship piloting and emergency call dispatch centres. In each chapter the authors present data and their analyses illustrate a variety of ways in which, despite imperfect systems, safety and resilience is created in human action. In the chapters where the focus is on error or mistakes, the analysis undertaken reveals the logic of actions undertaken at the time as well as their constraints.