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 |  موضوع: كتاب An Engineer's View of Human Error - Third Edition الأربعاء 13 ديسمبر 2023, 11:52 am | |
| 
أخواني في الله
أحضرت لكم كتاب
An Engineer's View of Human Error - Third Edition
Trevor Kletz
The theme of this book - Try to change situations, not people
و المحتوى كما يلي :
Contents
Foreword tothethird edition vi
1 Introduction
11 Accept men as we findthem
1 2 Meccano ordofs? 3
1 3 Typesofhuman error 4
1.4 Twosimpleexamples 6
1.5 Accident investigation 8
16 Astory 9
1 7 Researchonhuman error 10
2 Accidents causedbysimple slips 11
2 1 Introduction 11
22 Forgetting toopenorcloseavalve 13
23 Operatingthewrongvalve 21
24
Pressingthewrong button 25
25 Failuresto notice 29
2.6 Wrong connections 31
27 Errorsincalculations 32
2.8 Other medicalerrors 34
2.9 Railways 35
210 Otherindustries 41
211
Everydaylife(and typing) 43
2.12 Fatigue 45
3 Accidentsthatcouldbeprevented bybeftertrainingorinstructions 48
3 1 Introduction 48
32 Three Mile Island 50
33 Otheraccidentsthat could be
prevented byrelatively sophisticated training 53
34 Accidentsthat could be
prevented byelementary training 62
35 Contradictory instructions 65
36
Knowledge ofwhat we don't know 66
vii37 Some simpleways ofimprovinginstructions 67
3.8 Training orinstructions? 72
3.9 Caseswhentrainingisnot thebestanswer 74
4 Accidentsduetoalackofphysicalormental ability 78
41
People asked to do thephysicallydifficultorimpossible 78
42 People askedtodo thementallydifficultorimpossible 80
4.3 Individual traits andaccident proneness 85
4.4 Mind-sets 88
5 Accidents due tofailures tofollow instructions 97
5.1 Accidentsduetonon-compliance bymanagers 99
5.2 Accidents duetonon-compliance byoperators 103
5.3 Actionstoimprovecompliance 107
54 Alienation 109
55
Postscript 110
6. Accidentsthatcouldbyprevented bybettermanagement 112
6.1 An accidentcaused byinsularity 114
62 An accident duetoamateurism 115
6.3 The fire at King's Crossrailway station 116
64 TheHeraldofFreeEnterprise 117
65 The
Clapham Junction railway accident 118
6.6 PiperAlpha 120
67 What morecan seniormanagersdo? 120
6.8 Themeasurement ofsafety 125
6.9 Conclusions 127
7 Theprobability ofhumanerror 129
7.1 Whydo we needtoknow human errorrates7 130
72 Human errorrates —asimpleexample 132
73 Amorecomplexexample 132
7.4 Otherestimatesofhuman errorrates 136
75 Two moresimpleexamples 141
7.6 Buttonpressing 144
7.7 Non-process operations 146
78 Train drivererrors 147
7.9 Some pitfalls inusingdata on humanreliability 147
7.10 Dataonequipment maybedata onpeople 149
Viii7.11 Whomakes theerrors7 151
7.12 Conclusions 151
8 Some accidentsthatcouldbeprevented bybetterdesign 154
8.1 Isolation of protective equipment 155
82 Better information
display 156
8.3 Pipe failures 156
8.4 Vessel failures 159
85 TheSellafield leak 159
8.6 Otherdesign errors 161
87
Conceptual shortcomings 162
8.8 Problems of
design contractors 165
89 Domestic accidents 166
9 Some accidentsthatcouldbeprevented bybetterconstruction 168
91 Pipefailures 168
9.2 Miscellaneous incidents 170
93 Prevention ofconstruction errors 173
10 Some accidentsthatcouldbeprevented bybettermaintenance 175
10 1 Incidents which occurred becausepeopledid notunderstand how
equipmentworked 175
10.2 Incidents which occurred becauseof
poormaintenance practice 178
103 Incidents dueto
gross ignorance orincompetence 180
104 Incidents which occurred becausepeopletook shortcuts 181
105 Incidents which could beprevented bymorefrequentorbettermaintenance 183
10.6 Can we avoidtheneedforsomuch maintenance? 185
11 Some accidents thatcouldbeprevented bybettermethods
ofoperation 187
111 Permits-to-work 187
112 Tanker incidents 189
113 Some incidents that could be
prevented bybetterinstructions 192
114 Some incidents
involving hoses 193
11.5 Communication failures 194
11.6 Examplesfrom therailways 199
11.7 Simple causesinhightechindustries 201
12 Errors incomputer-controlled plants 203
12.1 Hardware failures 204
122 Software errors 205
123 Specification errors 207
12.4 Misjudging responsestoacomputer 210
ix125 Enteringthewrongdata 213
126 Failurestotelloperators ofchangesindataorprograms 214
12.7 Unauthorized interference withhardware orsoftware 214
128 Thehazardsofoldsoftware 217
12.9 Otherapplications ofcomputers 217
12.10Conclusions 218
13 Personal andmanagerial responsibility 221
13.1 Personalresponsibility 221
132 Legalviews 223
133 Blame inaccident investigations 227
134
Managerial wickedness 228
135 Managerial competence 229
136 Possibleandnecessary 231
14 Theadventures ofJoeSoapand John Doe 234
15 Somefinal thoughts 254
Postscript 257
Appendix 1 —Influences onmorale 258
Appendix2—Somemythsofhuman error 26]
Appendix 3—Somethoughts on sonataform 269
Further reading 271
Index 273
xIndex
A
Aberfan
ability,lackof
Aborigmes
access
accidentinvestigation
accidentstatistics
accident—prone
acetone
2, 99, 118, 125,
129, 155, 178, 189
Australia 123, 148
123 auto—pilot 11—12
79 automatic train protection 39—40
automation 83—84, 104, 116,
130—131, 191,253,263
andpeople compared 84, 143,
199 207—208, 211
acids 45, 53,58. 192—194, 199
254
32,53
9, 17,41, 146—147,
161,213—214,227
Aisgill 38
alarmoverload 80—82
alarms 21—22,53,58, 65—66, 74, 80—81,
100—101, 105, 125, 130, 149—150,
155,204—205, 207,210-211,263
alertness 83—84, 198,215
alienation 109—110
amateurism 115
ambulances 83
Amish
ammonia
anaesthetics
appearance, incorrect
asbestos
assembly
incorrect
probability oferrors
attitudes
B
back injuries
batchprocesses
errors, probability of 140, 143—144
behavioural safetytraining 12, 75,
176, 229
behavioural science techniques 107—109
bellows 150, 159, 169, 173, 261—262
BelvoirCastle 110
beveragemachines 25—26, 144—146, 150
Bhopal 121
Bible 74,226
bicycles 85
110 'black book' 53
blackbox 207,209
blame 8—9, 37,97—98. 104, 113, 182,
213, 221,225—229,263,266—267
blind
eye 65,99, 104, 119, 124,225,263
boilers (seealso waste heatboilers) 17.
84, 105,155,179,184—185
bolts
botching 63, 169
audits
184, 229
78—94
122—123, 227
1,87
12, 85—88
'ActsofGod'
agitation
aircraft
75
169,190
31,35
34
225
121
157, 161
146
75, 257
175
273AN ENGiNEERS 'flEE OF NOMAN ERROR
box girderbridges 57 colour—coding 22—24,26, 30, 32,74,
brakes 200 175,179,212
breathingapparatus 62,78, 161, colunmsupports 91—92
179, 182 commonlaw 76
bridges 57 commonmodefailure 22
burstingdiscs 251 cornmumcation 119, 124. 208—210
buttons 25—29, 144—146,250 byradio 199
probabilityofpressingerrors144—146 verbal 198—199
Byng,Admiral 74 written 194—197
complexity 22, 121, 163. 266
compressed air 61, 161,179,
194,200,209,265
C compressed gases 72
cablerailways 9 powerof 54
cables 176 compressorhouses 170
calculation errors 32—34,213 compressors 78, 169—170
cars 6. 16,43, 63—64, 105, 151, 265 computerdisplays 211
causes computers 8, 81,203—218
underlying 114-120.122—123 calculationsby 217
versus actions 255 capability exaggerated 207,215
caustic soda 193 errorsinentries 212—214,216
chance 86—87 hardware failures 204—205
Channel Tunnel 65—66 responsesto 210—213
Chazops 209 retentionofdata 211
check—lists 16 software errors 205—206
checks 99, 104—107, 117—118, specification errors 208—210
147—149, 155, 169, 181, 196. 201 condensate 198
weakness of 119 connections, wrong 31
chemicalburns 20, 58, 182—183 connectorsforhoses 31—32,187—189.
Chemobyl 52, 101—102 193—194
Chinley 38 conspiracy 94
chlorine 62 construction 57,81—82, 157,
chloroform 31 168—173,261
chokes 50, 53—55, 91 contamination 192
clamps 43 contractors 56, 64, 110, 115, 165, 172
ClaphamJunction 45, 118—119,228 contradictory mstructions 65—66, 73
classification systems 4,7, 26 controlrooms 27, 131—132
cleaning 193 corrosion 104, 157, 201
clocks 43—44 ofprocedures 4
clumsiness 79 costs 40, 113, 121, 125, 185
cognitivedissonance 94 cranes 17,27, 57,78, 84
cokers 89—90 creativity 267
collierytips 184 crime 221—226
274INDEX
culture 88, 109, 112, 176, electncalareaclassification 164
258—260,265 electrical equipment 64.79, 148, 164,
cylinders 62, 78, 177-479,245 178,204,244
electricity, isolation of 17. 148
D emergency evacuation 85
databases 124—125 entry toconfinedspaces 71. 179,196,
dates 214 247.251
dead—ends 169 equipment
debottlenecking 164 failures 149—150
defenceindepth 79 flameproof 178
demanning (see manpower, identification of 180, 187—189,235,
reductions in) 248,250
demolition 44 opening of 13—16,209
design 2—4,12. 16,20—23.32—34,41, errors(seealsotraindrivererrors)
43, 57,66, 80—81,91, 115, inbatchprocesses 140, 143—144
117—118, 154—166, 170, 173, 265 bymanagers 112—125
alternatives 23—24,121,162—165 definition of v
buildandmaintain' 185 medical 31, 34—35,214
designliaison 164—165, 172 innumbers 30—31
diagnosis 48, 52,94 measurement 146
dieselengines 90, 115 opportunities for 3
dimensions, estimatrnn of 85 probability of 6, 16,26, 90,
directors, responsibilities of 112—125 120,129—152
discretion 73 examples 131—146
discussions 50, 56,71, 84,98. 103, 155 limitations 129—130, 147—151
distillation columns 17,54, 132 reasons for 130—131
distractions 26, 130, 146 insoftware 205—206
documents, ancient 93 recoveryfrom 27
dolls 3 escalators 116
domestic accidents 43—44, 166, 240 ether 255
drain valves 17—21, 63, 183,235,253 ethylene 31—32,91, 114. 163
drowning 166 ethyleneoxide 163
drums 30,56,64 events,rare,detectionof 82
duplication, effecton eveiydayerrors 12
probability oferror 147—149 everydaylife 11
dusts 61, 100, 201 evidenceignored(seemind—sets)
expectations 84—85
experiments 102
E expertsandamateurs 115
education 48—76, 124 explosion venting 170
of
managers 113, 125 explosions 31—32,58,61, 64.66—67,71,
Einstellung 88 80,90, 100, 105, 109, 114, 120,
electricplugs 74 163, 170—171, 184,202,211,238,242
275AN ENGINEER'SVIEW OF HUMAN ERROR
F hazard and operability
falls 105, 166 studies (Hazop) 20, 61—62,91, 155,
fatalaccident rate 231 160, 165,205,207—210,
fatigue 45—46, 118, 166 212—213, 232, 261
ofmetals 168 hazards, hidden(seealso
fencing(ofmachinery) 224 forgottenhazards) 113
Feyzin 55—56 Hazop(seehazard andoperability
filters 13—15,30, 54, studies)
61, 109. 177, 209 Healthand Safety atWorkAct 229
fires 20,28, 32,36, 55,65—66, HeraldofFreeEnterprise 117—118
72, 100, 109, 115—1 16, 120, HomeGuard 48
125, 156—157, 166, 172, 175, hoses 32, 61, 187—189,
183, 191, 193, 199, 244, 261 193—194.200,243,265
fire—fighting 44, 85, 222 hydrogen fluoride 202
flamearresters 99, 184 hydrogen sulphide 78
flameproofequipment 178 hygienic factors 258—260
flarestacks 45, 91
Flixborough 66—67,121,163,215 I
foam—over 239 ICI 1,231
forceand
pressure confused 54 identification ofequipment 180,
forgery 222 187—189, 235, 248, 250
forgetfulness 11—46 ignition 114, 116, 171, 199, 261
forgottenhazards 53, 62,64, 72, 109, ignorance 53—67, 103, 164,
119, 123—124, 164, 175—180, 183. 265
184, 234—253, 264 indicatorlights 17—18
Freud 12 information 267
friendlydesign(seeuser-friendly design) information display
full—scale deflection 91 (seealsolabels) 126, 156
furnaces 29, 90, 170, 244 information overload 80—81
information retrieval 124
inherently saferdesign 52, 120—121,
G 151—152, 162—163,
gaskets 180, 252 165, 206, 265—266
'glassboxes' 209 initiative 5,98, 106
goodengineering practice 168 insects 49
gravity 2 inspection 56, 125, 168, 173,
greyhairs 4 178—179, 261
instability(ofprocesses)
(seealso runaway reactions) 101—102
H instructions 2—7.15,20,48—76, 107,
habits 84—85 113, 119. 192—193,
hangers 176 206—208. 230
Harrow 39 contradictory 65, 73
276lost
ways ofimproving
instrumentfailure
insularity
intention changes
interlocks (see alsotrips)
inventories, needtoreduce
J
K
keys(seebuttons)
kinetichandling
King's Cross
knowledge, failuretouse
knowledge—basedtasks
ontowater
lecturedemonstrations
legalresponsibility
libranes
liftinggear
lightbulbs
liquefiedflammable gas
liquefiedpetroleum gas
(seealso propane)
liquidtransfers
lithiumhydride
Lithuania
lost—timeaccidentrate
lubrication
M
machines andpeople compared 83—84
maintenance 4,17,27—29,99, 175—185
avoiding theneed 185
ofinstructions 71
isolationfor 17
preparation for 16, 27—29,32,72,
81—82. 103—104, 115. 148,
180—183, 187—192,215,250
qualityof 63, 149—150, 183—185
management 2,5
education
errors
managenalresponsibility
managers
responsibilities of
senior, actionspossibleby
manpower, reductions in
112—125
120
60,67,
122—123, 178
manualhandling 75
materials ofconstruction 150, 156, 161,
169—170, 172, 201
187—191 effectoftemperatureon 54,58
measurement errors, probabilityof 146
measurement ofsafety 125
Meccano 3
mechanical handling 198
81 medicalerrors 31,34—35,214
45 Melbourne 57
221—226
memory (see forgotten accidents)
222 mercenaries 110
methanol 193
150 methodsofworking 17
100,190 mind—sets 38, 88—94,163, 180, 192
53,56
67—77
150
114
182—183
15, 18—20,22,
41, 204—206,
214—216, 266
121
INDEX
180
192
61—62
216
112—113,
230,260
150,201
joints 34, 55, 114, 178—180, 183, 193
judgement, premature 88—89
75
114, 116
10,54—56
5—6,72—74,
[44,208
L
labels
missing
ladders
lapsesofattention
113, 125
7, 112—125
227—231
law
layout
leaktesting
leaks
20, 26,28, 30, 53,60, 80,
248,250,252,263,265
21—22, 116
30, 79, 105, 249
vi,3—4,8—9.11—46,
201,227
225—226, 264
22—23,75,79. 80, 115. 262
31—32.34,58, 62, 109,
114—115, 121, 159—160,
176, 178, 182, 193—194,
199,201.211,215,261
43, 92—93, 179
277RN ENGINEER' S vIEW Oi RUMRN ERROR
N
27
v, 5,78—94, 119
205
v,5—6,48—76
91—92, 160, 172,
206, 217, 264
58—59,214
214—216
6
39
109—110,258—260
107
258—260
269—270
261—267
navalwarfare 73, 83
nearmisses 126
negligence 266
nitrogen 171, 187—189,237
blanketing 164—165,204
non—compliance(seeviolations)
normalaccidents 266
notices 20
nuclear
powerstations 50—52,101—102,
151, 185,201—202, 216,266
numbers, errors in 30—31
nutsandbolts 179, 185
0
oldequipmentandsoftware 217
open containers 236
opening equipmentunderpressure 13—16
opemngfullequipment 209
options forthefuture 164
organizational failures 101, 112
overfilling 189—190. 193. 242
overheating (seealso
runawayreactions) 55, 101—102, 156,
179, 196, 245
p
13—16,54,60,64,
91, 100, 156, 159
132—134
163
pacemakers 214
Paddington 40
paraffin 163
parchments 93
patience 94
performance shaping factors 136
permits—to—work 16—17,81—82,
103—104, 125, 148. 171,
179, 180—183, 187—192, 198
personality, effectonaccidents of 86
petrol 63, 80, 200
green
phonetic alphabet
phosgene
pictorialsymbols
pigs
piloterror
pipesupports
pipebridges
PiperAlpha
pipes
plastic
pitfalls
poisoning
policy
statementsof 100
polyethylene 31—32
powder 61
preparationformaintenance 250
pressure,excessive
(seeoverpressunng)
pressurevessels (seealsoreactors)13—16
probability data (see errors,
probability of)
problems, disappearance of 255
propane 55
overprcssuring
probability of
oxygen
mirrorimages
mismatches
missiles
mistakes
modifications
peoplenottold
unauthorized
monitoring
Moorgate
morale
motivational appeals
motivators
music
myths
63
198
169
196
54
41
168—169
33
120
150, 156,
240,246
58
147—149
45. 196
120
53—54,60, 66,
168. 217
278prosecution
protective clothing
protective equipment(see also
alarms, automation,
interlocks, trips) 4,38, 121—122,
162—163, 165, 189—190,225
isolation of
protective systems
protoplasm
psychogemc illness
pumps
automatic start
pushbuttons (see buttons)
Q
Qumtinshill
R
railways 32,35—40,45, 80,82—83,
85—87, 104—105, 147,
184—185, 198—201, 228, 253
station fife
Rasmussen Report
reactions
reactors(seealso nuclearpower
stations) 18—20,25,27—30,63—65,
72, 100, 163, 179, 192—193,
207,211,212
recordsheets 62,91
recoveryfromerror 1,27, 146, 149
refrigeration 91
reliability,high 149
reliefvalves 20—21,51, 55,57,90—91,
104—105, 156, 159, 182, 184,
190—191, 193,252—253, 266
repeatedaccidents (seeforgotten
hazards)
research 10
respirators 30
responsibility
227—231
221
151—152
43
61
105
122—123
5—6,72—74, 144, 208
97—110
208,264
66
30,32, 53,63—65,
207—208, 211
251
117—118
36, 104, 181—183,189
35—38, 83, 85—86,
198, 200—201
signals passedatdanger
(SPADs) 38—40,80,82—83, 86,147
similarnames 198—199
simplicity 22, 121, 163
'skillofthecraft' 161,178
skill—based tasks
slips
5—6. 72—74, 144
vi,3—4,8—9,11—46,90,
118—119,205,213,227,266
103
INDEX
225 managerial
58. 104, personal
181—182,238 risks,tolerability of
roadaccidents
roadtankers
roofs,falls through
rootcauses
155 rule—based tasks
53 rules,violations of
255 rules(see alsoinstructions)
87 relaxationof
20—21,53,62, 82, runaway reactions
90, 182—183, 201
141—142 rupture discs
S
safety advisers 264
35—38 safetymanagement systems 122
Salem 94
sampling 238
scaffolding 54
scapegoats 73—74, 227, 230, 263
scenesofaccidents, visitsto 105
116
scrap 241
136, 138—139 'secondchance'design 160
30,32 self—inflicted injuries 87, 258
Sellafield 159—160
seniority 116
servicelines 116
settling 160
shipping
shortcuts
signalmen'serrors
legal 221—226 smoking
279AN ENGINEER'S VIEW OF HUMAN ERROR
software,inscrutable
software tests
spacerockets
SPADs(seesignals passed atdanger)
Spain
spares
spellingerrors
spilages
staticelectricity
steam
steamdrums
stirring(seeagitation)
stores,unofficial
stress
stressconcentration
supervision
supervisors, overloading of
systemfailures
T
effectonerrors
tolerance (ofmisuse)
'trackcircuits'
190 traindrivererrors
37, 118
81
tailors 9
tankers 63, 189—192, 194,200,237,243
tanks 56, 70, 80,91, 100,
160,171-472,184
overfilling, probability of 143
taskoverload 81
taskunderload 83—84
tasks,difficult 98
teamworking 60
telephonenumbers 43
temperature, effectonmaterials of54,58
construction
TESEO 136—137
4, 21—22,62,72. 100—102,
104—106, 119, 237—238, 242
105—106
205—206
V
vacuum
valves(seealso
drainvalves)
263
144
121, 173
37—38
38—40,80,
82—83,86. 104, 228
147
209 time
205—206
217
106, 109
7—8
191, 204, 209, 237, 253
13,60, 91, 180, 201. 240
12,26, 43, 130,
142—143, 146,166
probability of
training 2—8,11—12,48—76, 84,
61 113, 124, 168, 173. 178—179.
181, 189, 193, 215
22 unavoidable dependence on 143
transfers ofliquids 156, 159—160
106 trapped liquids 109, 175
trapped pressure 176, 183, 194, 243
traps 26,41
161 trips(seealsointerlocks) 21—22, 32, 50.
100—101, 125, 131, 155—156,
190, 204—206, 263. 266
101 turbines 50
tyres 156
U
unconscious mind 11—12
unforeseen hazards 234—253
unforeseen problems(see also
modifications) 211—212
university degreecourses iii
user—friendly design 3,52, 120—121,
206,212,248,249,
251—252,266
62
13—24, 22—23,27—29,
65, 79, 109. 131—132, 151,
175, 177, 180. 182, 190,
199,212,214—215
vehicles (seealsocars) 84—86,156,
198,245,262
172, 178
tests
hail—clone
software
theft,avoiding
THERP(TechniqueforHuman
ErrorRatePrediction)
ThreeMileIsland
222
136, 140
280
50—52 ventilation1I4DEX
vents 20—22,63, 79, 90, 184, W
193—194,236,239,246 wasteheatboilers 22, 74
verbs,irregular 98,265 wastematerial 202
vesselfailure 55, 159, 192—193, watchdogs 204—205
212,246 watchmen 83
vessels,sucked—rn 63, 184, 239 water 50—54. 172, 178,237,246
violations v, 5—6,8,97—110,118—119, electrolysis of 104
214—215, 227—229 waterhammer 60
bymanagers 99—102 weldfailure 201
byoperators t03—106 witches 94
canprevent accidents 106 wrong method,rightanswer 267
prevention of 97—98,107—109
ofrules 97—110 V
viruses 216 Yarranverbndge 57
visibility 78—79 Yugoslavia 227—228
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