Bibliografia Recomendada

Laboratório de Fatores Humanos - Out/2021

Abrashoff, M. (2002). Este Barco Também é Seu. São Paulo, BR: Ed. Pensamento- Amalberti, R. (2013). Navigating Safety: Necessary Compromises and Trade-offs –
Cultrix Ltda. Theory and Practice. Heidelberg: Springer.
Quando o capitão Abrashoff assumiu o comando do USS Benfold, um navio de guerra moderno, equipado com os Managing safety in a professional environment requires constant negotiation with other competitive dimensions of risk
sistemas mais avançados da atualidade, foi como se passasse a dirigir uma empresa com toda a tecnologia disponível, management (finances, market and political drivers, manpower and social crisis). This is obvious, although generally not
mas de baixa produtividade. Consciente de que a responsabilidade de melhorar o desempenho recaía sobre os seus said in safety manuals. The book provides a unique vision of how to best find these compromises, starting with lessons
ombros, ele compreendeu que precisaria desenvolver a sua própria capacidade de liderança antes de tentar aprimorar learnt from natural risk management by individuals, then applying them to the craftsman industry, complex industrial
o navio. Em poucos meses, Abrashoff conseguiu uma tripulação constituída de pessoas confiantes, motivadas a systems (civil aviation, nuclear energy) and public services (like transportation and medicine). It offers a unique,
solucionar problemas e dispostas a tomar iniciativas e assumir a responsabilidade pelos seus atos. O relato sobre como illustrated, easy to read and scientifically based set of original concepts and pragmatic methods to revisit safety
ele conseguiu este feito poderá ajudar você a mudar o curso do seu navio, não importa onde as suas batalhas management and adopt a successful system vision. As such, and with illustrations coming from many various fields
comerciais sejam travadas. (aviation, fishing, nuclear, oil, medicine), it potentially covers a broad readership.

Busch, C. (2016). Safety Myth 101. Musings on Myths, Misunderstandings and Busch, C. (2019). If You Can’t Measure It… Maybe You Shouldn’t: Reflections on
More. Middletown, DE: Mind the Risk. Measuring Safety, Indicators, and Goals
The Safety Profession has a problem. Over the past decades, it has been a fertile feeding ground for Myths, You drive to your job on a beautiful Monday morning. The speedometer shows a steady just-below-50 km/h. On the radio,
Misconceptions and Misunderstandings. Pyramids, dominos, ratios, certification, zeros, absolutes, rules, audits, positive the newsreader tells you about the unemployment figures, the number of casualties of an earthquake in South-East Asia,
mind-set, culture change, observation schemes, checklists, best practices, slogans, Safety First, errors, root causes and and that the Dow Jones has fallen some points. Upon entering the gate of your company, you pass a sign that proudly
risk matrices. You name it and someone will probably have twisted it into something that it should not be, through announces that today is the 314th day since the last Lost Time Injury. In the hallway, you see the LEAN Kanban board that
mechanisms like visions-turned-goals, tools out of context, black and white thinking, means-becoming-the-goal, rituals shows, among other things, production figures and sick leave statistics. At 8:30, you are all expected to gather around the
without proper understanding, correlation instead of causation or belief in Silver Bullets. This book collects 123 (and board and discuss what is presented there. In the elevator to your floor, you quickly check what has happened on
then some) of these Safety Myths. Crisp and compact discussions address weaknesses of conventional safety ‘wisdom’ Linkedin. You are pleased to see the number of ‘likes’ that your latest post has drawn. You walk on to your desk where you
and give suggestions for alternative approaches and improvement. The author mixes over two decades of professional see a pile of papers. On the top is a copy of the newest balanced scorecard that your boss’s secretary must have dropped
experience, theory, practice, anecdotes, examples, and not in the last place humor, into a very readable and easy to there, Friday afternoon. While sipping your first coffee of the day, you check your calendar and are reminded of the
understand different view on safety. annual performance review at 10 O’clock.So far, you have not done one tiny piece of actual work, but you have been
confronted with a mass of figures, measurement and metrics already. They are around us, all the time. But why? Do they
help? How to deal with them? This little book intends to help you think about them in different, maybe better, ways and
handle them better.Thirty rather compact chapters offer a critical view on measuring, indicators, metrics, goals and
statistics within a context of safety. The book also tries to offer some useful and practical suggestions for different
(possibly even better) approaches, or at least different ways to think about these subjects.

Busch, C. (2021). The First Rule of Safety Culture: A Counter-C-Word Manifesto. Carrillo, R. A. (2020). The Relationship Factor in Safety Leadership. Achieving Success
Middletown, DE: Mind the Risk. through Employee Engagement. New York, NY: Routledge.
Does the World really need another book about Safety Culture? Were this a book about how to engineer, create, build, At the core of The Relationship Factor in Safety Leadership are eight beliefs about human nature that are common to
or manage your Safety Culture, the answer would be a clear NO! However, this is not one of those books. This book is leaders who successfully communicate that safety is important while meeting business results. Using stories and business
not a Safety Culture as the Path to Bliss in Five Steps-type text. This book is about thinking critically about Safety language the book explains how to create and recover important stakeholder relationships by setting priorities and taking
Culture. The world desperately needs books with that perspective. action based on these beliefs.
Structured into six parts, around forty compact chapters discuss Safety Culture discourse, approaches, and applications The beliefs are based on the author’s 25 years of experience supporting operational and safety leaders with successful and
critically. For example, whether we should see culture as a tool to fix something or rather as a lens to study and unsuccessful change efforts in pharmaceutical, nuclear, mining, manufacturing, and power generation. The author also
understand. And if you ever wanted to become a culture architect, hopefully you will think twice after reading this. offers compelling evidence from many social and scientific disciplines that support the conclusion that satisfying our need
The book also tries to offer some useful and practical suggestions for different (possibly even better) approaches, or at for relationship is a major motivator.
least different ways to think about these subjects. These suggestions for more fruitful ways forward include The First The Five Orientations Model offers a perspective on solving complex problems when confronted with multiple demands.
Rule of Safety Culture. The book provides managers and supervisors with the motivation to build relationships and points to the conditions
needed for success. It also describes a process to take united action but retain the flexibility to change course as
necessary.
The book is written for managers and leaders, at all levels, concerned with occupational health and safety, and wishing to
learn how to leverage relationships to achieve higher employee engagement and performance.
Concklin, T. (2012). Pre-Accident Investigations: An Introduction to Organizational Concklin, T. (2017). Workplace Fatalities. Failure to Predict. Santa Fe, NM:
Safety. Boca Raton, FL: CRC Press CreateSpace Independent Publishing Platform
Time-pressed, professionals looking for practical guidance to shape their current or future safety programs should A New Safety Discussion on Fatality and Serious Event Reduction.
use this book. Pre-Accident Investigations: An Introduction to Organizational Safety helps to identify complex Many organizations tell us that work has never been as safe as it is today. They will show the lowest injury figures ever,
potential incidents before they take place. Based around the ’New View’ of human error, it offers established human and the rosiest incident counts in years. They want to be proud of these accomplishments, and perhaps they should be.
performance theory in a highly practical context. Written in an engaging, conversational style, around several case But behind these results hides complexity and contradiction—a messiness that Todd Conklin takes us into with this
studies, the book is grounded in reality, with examples with which anyone can identify. It is an ideal aid for senior book. For one, it is pretty obvious by now that trying to lower our incident and injury rates leaves the risk of process
safety executives who want to spread the safety message among their colleagues. It is also an excellent choice for safety disasters and fatalities pretty much unaffected. Getting better at managing injuries and incidents doesn’t help us
course tutors looking for a narrative-led primer. prevent fatalities and accidents—we’ve known that for a long time (Salminen, Saari, Saarela, & Rasanen, 1992). The
number of fatalities in, say, construction, or the energy industry, has remained relatively stable over the past decades
(Amalberti, 2013; National-Safety-Council, 2004), even when many organizations proudly report entire years (or more)
without injury. Lowering the injury or non- serious incident rate can actually put an organization at greater risk of
accidents and fatalities. In shipping, for example, injury counts were halved over a recent decade, but the number of
shipping accidents tripled (Storkersen, Antonsen, & Kongsvik, 2016). In construction, most workers lost their lives
precisely in the years with the lowest injury counts (Saloniemi & Oksanen, 1998). And in aviation, airlines with the
fewest incidents have the highest passenger mortality risk (Barnett & Wang, 2000). What lies behind these fatalities?
Do they really happen because some people don’t wear their personal protective equipment; that some don’t wear
gloves when rules say they should? WorkPlace Fatalities: Failure to Predict is the first book for the industry professional
that speaks directly to this important challenge: If your organization is so safe - Why do we have fatal and serious
events?
Concklin, T. (2018). Pre-Accident Investigations: Better Questions - An Applied Concklin, T. (2019). The 5 Principles of Human Performance: A contemporary
Approach to Operational Learning. Boca Raton, FL: CRC Press. updateof the building blocks of Human Performance for the new view of safety.
Pre-Accident Investigations: Better Questions - An Applied Approach to Operational Learning challenges safety Santa Fe, NM: PreAccident Media
and reliability professionals to get better answers by asking better questions. A provocative examination of Conklin’s book is an interesting and informal discussion with the reader about the 5 Principles of Human
human performance and safety management, the book delivers a thought-provoking discourse about how we Performance principle by principle, chapter by chapter. These 5 theroies about how humans perform in organiations
work, and defines a new approach to operational learning. are principles, the building blocks of Human Performance, through which we have established a new way to think
This is not a book about traditional safety. This is a book about creating "real" safety in your organization. In about safety and reliability in our worlds. …and changing the way we think about work is a vital step towards
order to predict incidents before they happen, an organization should first understand how their processes can improvement.Work never stops and work is never normal. This idea would scare a mere-mortal manager, but an
result in failure. Instead of managing the outcomes, they must learn to manage and understand the processes enlightened leader knows the power of continuous learning and improvement. Work is constantly in motion,
used to create them. therefore learning must continue. Work is never the same, therefore we never really know how work is being done.
Ideal for use in safety, human performance, psychology, cognitive and decision making, systems engineering, and If we don’t know how we perform work how will we know how we can improve?The 5 Principles of Human
risk assessment areas, this book equips the safety professional with the tools, steps, and models of success needed Performance are, in a sense, a repository of the central values of Human Performance. Keeping these principles at
to create long-term value and change from safety programs. the core of our thinking, training, and practices will allow the basic building blocks of this philosophy to help
organizational programs reduce the normal philosophical drift that is present and predictable in all safety programs.
Having these espoused principles keeps us all honest and keeps our Human Performance effort on track and
successful.

Dekker, S. (2011). Drift into Failure: From broken components to understanding Dekker, S. (2012). Just Culture. Balancing Safety and Accountability (2nd. Ed.). Boca
complex systems. Boca Raton, FL: CRC Press. Raton, FL: CRC Press.
This book explores complexity theory and systems thinking to understand better how complex systems drift into Dekker revises, enhances and expands his view of just culture for this second edition, additionally tackling the key issue of
failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds how justice is created inside organizations. The goal remains the same: to create an environment where learning and
that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and accountability are fairly and constructively balanced. The First Edition of Sidney Dekker’s Just Culture brought accident
that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness accountability and criminalization to a broader audience. It made people question, perhaps for the first time, the nature
complexity and find new ways of managing drift. of personal culpability when organizational accidents occur. Having raised this awareness the author then discovered that
while many organizations saw the fairness and value of creating a just culture they really struggled when it came to
developing it: What should they do? How should they and their managers respond to incidents, errors, failures that
happen on their watch? In this Second Edition, Dekker expands his view of just culture, additionally tackling the key issue
of how justice is created inside organizations.

Dekker, S. (2014). The Field Guide to Understanding Human Error. Boca Raton, FL: Dekker, S. (2015). Safety Differently. Human Factors for a New Era (2nd. Ed.). Boca
CRC Press. Raton, FL: CRC Press.
This latest edition of The Field Guide to Understanding ‘Human Error' will help you understand how to move beyond Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking.
'human error'; how to understand accidents; how to do better investigations; how to understand and improve your Automation and new technologies have resulted in new roles, decisions, and vulnerabilities whilst practitioners are also
safety work. You will be invited to think creatively and differently about the safety issues you and your organization faced with new levels of complexity, adaptation, and constraints. It is becoming increasingly apparent that conventional
face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to approaches to safety and human factors are not equipped to cope with these challenges and that a new era in safety is
influence your own thinking and practice, as well as that of your colleagues and organization. necessary.
Dekker, S. (2018). The Safety Anarchist: relying on human expertise and Dekker, S. (2019). Foundations of Safety Science: A century or understanding
innovation, reducing bureaucracy and compliance. New York, NY: Routledge. accidents and disasters. Boca Raton, FL: CRC Press.
It is time for Safety Anarchists: people who trust people more than process, who rely on horizontally coordinating How are today’s ‘hearts and minds’ programs linked to a late-19th century definition of human factors as people’s moral
experiences and innovations, who push back against petty rules and coercive compliance, and who help recover the and mental deficits? What do Heinrich’s ‘unsafe acts’ from the 1930’s have in common with the Swiss cheese model of the
dignity and expertise of human work. Bureaucracy and compliance now seem less about managing the safety of the early 1990’s? Why was the reinvention of human factors in the 1940’s such an important event in the development of
workers we are responsible for, and more about managing the liability of the people they work for. We make safety thinking? What makes many of our current systems so complex and impervious to Tayloristic safety interventions?
workers do a lot that does nothing to improve their success locally. Paradoxically, such tightening of safety ‘Foundations of Safety Science’ covers the origins of major schools of safety thinking and traces the heritage and
bureaucracy robs us of exactly the source of human insight, creativity and resilience that can tell us how success is interlinkages of the ideas that make up safety science today.
actually created, and where the next accident may well happen.

Dekker, S. (2021). Compliance Capitalism (The Business, Management and Safety Dingee, A. (2018). Delivering the Right Stuff: How the Airlines' Evolution in Human
Effects of Neoliberalism). New York, NY: Routledge. Factors Delivered Safety and Operational Excellence. Middleton, DE: Lulu Publishing
In this book, Sidney Dekker sets out to identify the market mechanisms that explain how less government paradoxically Services.
leads to greater compliance burdens. This book gives shape and substance to a suspicion that has become widespread As the space and aviation industries matured, they quickly learned that relying on men and women to have the "right
among workers in almost every industry: we have to follow more rules than ever―and still, things can go spectacularly stuff" does not work. Several high-profile fatal airline accidents led to the creation of a new term-"Human Factors."
wrong. Delivering the Right Stuff examines the airline industry's investigations into Human Factors and details how key findings
Much has been privatized and deregulated, giving us what is sometimes known as ‘new public management,’ driven from aircraft accidents shaped its acceptance of pilot error. It is an evolution that delivered transferrable frontline tools
by neoliberal, market-favoring policies. But paradoxically, we typically have more rules today, not fewer. It’s not the that forged a foundation for safety and operational excellence.
government: it’s us. This book is the first of a three-part series on the effects of ‘neoliberalism,’ which promotes the
role of the private sector in the economy. Compliance Capitalism examines what aspects of the compliance economy,
what mechanisms of bureaucratization, are directly linked to us having given free markets a greater reign over our
political economy. The book steps through them, picking up the evidence and levers for change along the way.
Dekker’s work has always challenged readers to embrace more humane, empowering ways to think about work and
its quality and safety. In Compliance Capitalism, Dekker extends his reach once again, writing for all managers, board
members, organization leaders, consultants, practitioners, researchers, lecturers, students, and investigators curious
to understand the genuine nature of organizational and safety performance.
Edmondson, A. (2018). The Fearless Organization: Creating Psychological Safety in Edwards, R., and Baker, A. (2020). Bob’s Guide to Operational Learning. How to
the Workplace for Learning, Innovation, and Growth. New York, NY: John Wiley & think like a Human and Organizational Performance (HOP) Coach. Santa Fe, NM:
Sons. Pre-Accident Investigation Media.
The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth offers Welcome! We are glad you are here. This book is for all of you. For all of us. For the people working hard each day to
practical guidance for teams and organizations who are serious about success in the modern economy. With so much apply HOP principles in our organizations and in our lives. We have spent 7+ years on our HOP journey and have struggled
riding on innovation, creativity, and spark, it is essential to attract and retain quality talent—but what good does this through the challenge of turning theory into action. We wrote this book to share what we have learned about Operational
talent do if no one is able to speak their mind? The traditional culture of "fitting in" and "going along" spells doom in Learning, Learning Teams and Industrial Empathy. We hope it is simple, practical, useful, real, raw and inspiring. We hope
the knowledge economy. Success requires a continuous influx of new ideas, new challenges, and critical thought, and you take everything you can from it, but don’t feel constrained by it. We hope you build on what we have created, improve
the interpersonal climate must not suppress, silence, ridicule or intimidate. Not every idea is good, and yes there are on what we’ve shared, and pass on your ideas to others.
stupid questions, and yes dissent can slow things down, but talking through these things is an essential part of the
creative process. People must be allowed to voice half-finished thoughts, ask questions from left field, and brainstorm
out loud; it creates a culture in which a minor flub or momentary lapse is no big deal, and where actual mistakes are
owned and corrected, and where the next left-field idea could be the next big thing.
This book explores this culture of psychological safety and provides a blueprint for bringing it to life. The road is
sometimes bumpy, but succinct and informative scenario-based explanations provide a clear path forward to constant
learning and healthy innovation.
• Explore the link between psychological safety and high performance
• Create a culture where it’s “safe” to express ideas, ask questions, and admit mistakes
• Nurture the level of engagement and candor required in today’s knowledge economy
• Follow a step-by-step framework for establishing psychological safety in your team or organization
Shed the "yes-men" approach and step into real performance. Fertilize creativity, clarify goals, achieve accountability,
redefine leadership, and much more. The Fearless Organization helps you bring about this most critical transformation.
Flin, R., O`Connor, P., and Crichton, M. (2008). Safety at the Sharp End: A Guide to Hollnagel, E. (2014). Safety-I and Safety-II. The Past and Future of Safety
Non-Technical Skills. Aldershot, UK: Ashgate Publishing Ltd. Management. Boca Raton, FL: CRC Press.
Safety at the Sharp End is a general guide to the theory and practice of non-technical skills for safety. It covers the This book analyses and explains the principles behind both approaches and uses this to consider the past and future
identification, training and evaluation of non-technical skills and has been written for use by individuals who are of safety management practices. The analysis makes use of common examples and cases from domains such as
studying or training these skills on CRM and other safety or human factors courses. The material is also suitable for aviation, nuclear power production, process management and health care. The final chapters explain the theoretical
undergraduate and post-experience students studying human factors or industrial safety programs. and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of
strategic management (safety culture).

Hollnagel, E. (2009). The ETTO Principle: Efficiency-Thoroughness Trade-Off. Why Hollnagel, E., & Woods, D. (2005). Joint Cognitive Systems. Foundations of Cognitive
Things That Go Right Sometimes Go Wrong. Systems Engineering. Boca Raton, FL: CRC Press.
Accident investigation and risk assessment have for decades focused on the human factor, particularly ‘human error’. Joint Cognitive Systems: Foundations of Cognitive Systems Engineering offers a principled approach to studying human
This bias towards performance failures leads to a neglect of normal performance. It assumes that failures and work with complex technology. The authors use a top-down, functional approach and emphasize a proactive (coping)
successes have different origins so there is little to be gained from studying them together. Erik Hollnagel believes this perspective on work that overcomes the limitations of the structural human information processing view. They describe a
assumption is false and that safety cannot be attained only by eliminating risks and failures. The alternative is to conceptual framework for analysis with concrete theories and methods for joint system modeling that can be applied
understand why things go right and to amplify that. across the spectrum of single human/machine systems, social/technical systems, and whole organizations. The book
The ETTO Principle looks at the common trait of people at work to adjust what they do to match the conditions. It explores both current and potential applications of CSE illustrated by examples.
proposes that this efficiency-thoroughness trade-off (ETTO) is normal. While in some cases the adjustments may lead
to adverse outcomes, these are due to the same processes that produce successes.

Hopkins, A. (2012). Disastrous Decisions – The Human and Organizational Causes Hopkins, A. (2019). Organising for Safety – How Structure Creates Culture. Sydney,
of the Gulf of Mexico Blowout. Sydney, Australia: CCH Australia Limited. Australia: CCH Australia Limited.
Hopkins takes the reader into the realm of human and organizational factors that contributed to the Deepwater How do we change the culture of an organization? The culture change industry assumes that this is best done with
Horizon disaster in 2010. It is important to know what people did, but even more important to know why they did it, educational campaigns - the hearts and minds approach. But this seldom works, because it does not come to terms with
so this book attempts to "get inside the heads" of decision-makers and understand how they themselves understood the real source of organizational culture - the way the organization is structured. This book explores just how
the situations they were in. It also seeks to discover what it was in their organizational environment that encouraged organizational structure shapes culture. It shows how decentralized organizational structures allow profit and production
them think and act as they did. to take precedence over safety, while centralized risk control is conducive to a culture of operational excellence.

Kahneman, D. (2011). Thinking, fast and slow. Farrar, Straus and Giroux. Le-Coze, J-C. (2021). Post Normal Accident. Revisiting Perrow’s Classic. Boca Raton,
In the international bestseller, Thinking, Fast and Slow, Daniel Kahneman, the renowned psychologist and winner of FL: CRC Press
the Nobel Prize in Economics, takes us on a groundbreaking tour of the mind and explains the two systems that drive Post Normal Accident revisits Perrow’s classic Normal Accident published in 1984 and provides additional insights to our
the way we think. System 1 is fast, intuitive, and emotional; System 2 is slower, more deliberative, and more logical. sociological view of safety-critical organisations. The operating landscape of high-risk systems has indeed profoundly
changed in the past 20 to 30 years but the core sociological models of safety remain associated with classics of the 1980s
and 1990s.
This book examines the conceptual and empirical evolutions of the past two to three decades to explore their implications
for safety management, based on several strands of works in various research traditions in safety (e.g. cognitive
engineering and system safety, high-reliability organisation, sociology of safety, regulatory studies) and other
interdisciplinary fields (e.g. international business, globalisation studies, strategy management, ecology).
Leveson, N. (2011). Engineering a Safer World. Systems Thinking Applied to Leveson, N., Woods, D., & Hollnagel, E. (2012). Resilience Engineering: Concepts and
Safety. Cambridge, MA: The MIT Press. Precepts. Farnham, UK: Ashgate Publishing Limited.
Engineering has experienced a technological revolution, but the basic engineering techniques applied in safety and For Resilience Engineering, 'failure' is the result of the adaptations necessary to cope with the complexity of the real
reliability engineering, created in a simpler, analog world, have changed very little over the years. In this world, rather than a breakdown or malfunction. The performance of individuals and organizations must continually adjust
groundbreaking book, Nancy Leveson proposes a new approach to safety―more suited to today's complex, to current conditions and, because resources and time are finite, such adjustments are always approximate. This definitive
sociotechnical, software-intensive world―based on modern systems thinking and systems theory. Revisiting and new book explores this groundbreaking new development in safety and risk management, where 'success' is based on
updating ideas pioneered by 1950s aerospace engineers in their System Safety concept, and testing her new model the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm
extensively on real-world examples, Leveson has created a new approach to safety that is more effective, less occur.
expensive, and easier to use than current techniques. Arguing that traditional models of causality are inadequate,
Leveson presents a new, extended model of causation (Systems-Theoretic Accident Model and Processes, or STAMP),
then shows how the new model can be used to create techniques for system safety engineering, including accident
analysis, hazard analysis, system design, safety in operations, and management of safety-critical systems.

Lloyd, C. (2020). Next Generation Safety Leadership. From Compliance to Care. Motet, G., and Bieder, C. (2017). The Illusion of Risk Control: What Does it Take to
Boca Raton, FL: CRC Press. Live with Uncertainty? Cham, SZ: SpringerOpen.
This book illustrates practical applications that bring theory to life through case studies and stories from the author's This book explores the implications of acknowledging uncertainty and black swans for regulation of high-hazard
years of experience in high-risk industries. The book provides safety leaders and their organizations with a compelling technologies, for stakeholder acceptability of potentially hazardous activities and for risk governance. The conventional
case for change. A key predictor of safety performance is trust, and its associated components of integrity, ability, and approach to risk assessment, which combines the likelihood of an event and the severity of its consequences, is poorly
benevolence (care). The next generation of safety leaders will take the profession forward by creating trust and suited to situations where uncertainty and ambiguity are prominent features of the risk landscape. The new definition of
psychological safety. The book provides safety leaders with actionable goals to enable positive change and translates risk used by ISO, “the effect of uncertainty on [achievement of] one’s objectives”, recognizes this paradigm change. What
academic languages into practical applications. It leaves the reader with a clear strategy to move forward in lessons can we draw from the management of fire hazards in Edo-era Japan? Are there situations in which increasing
developing a safety plan and utilizes stories, humor, and case studies set in high-risk industries. Written primarily for uncertainty allows more effective safety management? How should society address the risk of potentially planet-
the safety community and can be used to influence day to day safety operations in high-risk organizations. destroying scientific experiments? This book presents insights from leading scholars in different disciplines to challenge
current risk governance and safety management practice.

Perrow, C. (1999). Normal Accidents: Living with high-risk technologies. Princeton, Reason, J. (1997). Managing the Risks of Organizational Accidents. Aldershot, UK:
NJ: Princeton University Press. Ashgate Publishing.
Normal Accidents analyzes the social side of technological risk. Charles Perrow argues that the conventional One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their
engineering approach to ensuring safety--building in more warnings and safeguards--fails because systems complexity occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents
makes failures inevitable. He asserts that typical precautions, by adding to complexity, may help create new categories in a wide variety of high-technology systems.
of accidents. (At Chernobyl, tests of a new safety system helped produce the meltdown and subsequent fire.) By
recognizing two dimensions of risk--complex versus linear interactions, and tight versus loose coupling--this book
provides a powerful framework for analyzing risks and the organizations that insist we run them.

Rosenberg, M. (2006). Comunicação Não-Violenta. Técnicas para Aprimorar Sharman, A. (2019). Naked Safety. Exploring the Dynamics of Safety in a Fast-
Relacionamentos Pessoais e Profissionais (4ª Ed). São Paulo, BR: Editora Ágora. Changing World. New York, NY: Routledge
Manual prático e didático que apresenta metodologia criada pelo autor, voltada para aprimorar os relacionamentos Workplace safety has never been seen as sexy, clever or cool. Fraught with legislative hurdles, ambiguous policy and
interpessoais e diminuir a violência no mundo. Aplicável em centenas de situações que exigem clareza na comunicação: complex procedures, despite its alleged importance safety has lost its way. For many organisations safety is seen as
em fábricas, escolas, comunidades carentes e até em graves conflitos políticos. burdensome and bureaucratic and has become little more than paperwork and performance charts: things done in fear
of persecution – from the authorities, the media or the civil arena – rather than doing the right thing. To change the game
and build real risk literacy, it’s vital to make things easier, to strip things back to basics and think again about how we
work. This is Naked Safety.
This book is a useful, multi-purpose guide for professionals; an indispensable toolkit for practitioners, business leaders,
and anyone with an interest in workplace risk and Occupational Safety and Health. Let’s get Naked!
Shorrock, S., and Williams, C. (2017). Human Factors and Ergonomics in Practice. Smith, G. (2018). Paper Safe. The triumph of bureaucracy in safety management.
Improving System Performance and Human Well-Being in the Real World. Boca Perth, Australia: Wayland Legal Pty Ltd.
Raton, FL: CRC Press. At some point health and safety management seems to have lost its way. Rather than being concerned about protecting
This book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and workers and others from the hazards associated with business, health and safety management has devolved into a self-
experiences of practitioners and other stakeholders in a variety of industrial sectors, organizational settings and perpetuating industry which has driven a wedge between management and the workforce. Health and safety
working contexts. The book blends literature on the nature of practice with diverse and eclectic reflections from management has become synonymous with trivial rules and burdensome, never-ending paperwork. This book explores
experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the the question of bureaucracy in safety management. What is it, and how does it impact organizational goals for health
achievement of the core goals of HF/E: improved system performance and human wellbeing. The book should be of and safety? The book asks what we can do to better understand and deal with bureaucracy in health and safety
interest to current HF/E practitioners, future HF/E practitioners, allied practitioners, HF/E advocates and management, and ultimately what steps we can take to reconnect management, workers, and safety processes to
ambassadors, researchers, policy makers and regulators, and clients of HF/E services and products. achieve the best safety outcomes we can.

Snook, S. (2000). Friendly Fire. The Accidental Shootdown of U.S. Black Hawks Sutton, B., McCarthy, G., and Robinson, B. (2020). The Practice of Learning Teams:
Over Northern Iraq. Princeton, NJ: Princeton University Press. Learning and improving safety, quality, and operational excellence.
On April 14, 1994, two U.S. Air Force F-15 fighters accidentally shot down two U.S. Army Black Hawk Helicopters over Learning Teams from Dr Todd Conklin, PhD, are part of a way of looking at safety, quality, and operational excellence
Northern Iraq, killing all twenty-six peacekeepers onboard. In response to this disaster the complete array of military differently by a facilitated approach to worker engagement and supporting the empowerment of people to own safety,
and civilian investigative and judicial procedures ran their course. After almost two years of investigation with quality, or operational excellence. A Learning Team is notable because it encourages organizations to obtain and
virtually unlimited resources, no culprit emerged, no bad guy showed himself, no smoking gun was found. This book consider different perspectives and angles of functional diversity to define a problem in a group context.
attempts to make sense of this tragedy--a tragedy that on its surface makes no sense at all. His conclusion is
disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect
them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable
organization.

Vaughan, D. (1996). The Challenger Launch Decision. Risky Technology, Culture, Weick, K., & Sutcliffe., K. (2015). Managing the Unexpected. Sustained Performance
and Deviance at NASA. Chicago, IL: The University of Chicago Press. in a Complex World (3rd Ed). Hoboken, NJ: John Wiley & Sons, Inc.
Why did NASA managers, who not only had all the information prior to the launch but also were warned against it, This critical book focuses on why some organizations are better able to sustain high performance in the face of
decide to proceed? In retelling how the decision unfolded through the eyes of the managers and the engineers, unanticipated change. High reliability organizations (HROs), including commercial aviation, emergency rooms, aircraft
Vaughan uncovers an incremental descent into poor judgment, supported by a culture of high-risk technology. carrier flight operations, and firefighting units, are looked to as models of exceptional organizational preparedness. This
Diane Vaughan recreates the steps leading up to that fateful decision, contradicting conventional interpretations to essential text explains the development of unexpected events and guides you in improving your organization for more
prove that what occurred at NASA was not skullduggery or misconduct but a disastrous mistake. reliable performance.

Woods, D., Dekker, S., Cook, R., Johannesen, L., & Sarter, N. (2010). Behind
Human Error. Farnham, UK: Ashgate Publishing Limited.
Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a
'human error problem', and solutions are thought to lie in changing the people or their role in the system. For
example, we should reduce the human role with more automation, or regiment human behavior by stricter
monitoring, rules or procedures.