An Engineer's View of Human Error, Third

This title looks at how people, as opposed to technology and computers within plants, are arguably the most unreliable factor, leading to dangerous situations. Identifies accidents in process plants that could have been prevented by better training, management, design, construction, maintenance, and methods of operation. The author believes the inevitability of human error should be anticipated during the design process. The third edition adds more examples of accidents caused by human error.

Foreword to the third edition

iii

Introduction

1

(10)

Accept men as we find them

1

(2)

Meccano or dolls?

3

(1)

Types of human error

4

(2)

Two simple examples

6

(2)

Accident investigation

8

(1)

A story

9

(1)

Research on human error

10

(1)

Accidents caused by simple slips

11

(37)

Introduction

11

(2)

Forgetting to open or close a valve

13

(8)

Operating the wrong valve

21

(4)

Pressing the wrong button

25

(4)

Failures to notice

29

(2)

Wrong connections

31

(1)

Errors in calculations

32

(2)

Other medical errors

34

(1)

Railways

35

(6)

Other industries

41

(2)

Everyday life (and typing)

43

(2)

Fatigue

45

(3)

Accidents that could be prevented by better training or instructions

48

(30)

Introduction

48

(2)

Three Mile Island

50

(3)

Other accidents that could be prevented by relatively sophisticated training

53

(9)

Accidents that could be prevented by elementary training

62

(3)

Contradictory instructions

65

(1)

Knowledge of what we don't know

66

(1)

Some simple ways of improving instructions

67

(5)

Training or instructions?

72

(2)

Cases when training is not the best answer

74

(4)

Accidents due to a lack of physical or mental ability

78

(19)

People asked to do the physically difficult or impossible

78

(2)

People asked to do the mentally difficult or impossible

80

(5)

Individual traits and accident proneness

85

(3)

Mind-sets

88

(9)

Accidents due to failures to follow instructions

97

(15)

Accidents due to non-compliance by managers

99

(4)

Accidents due to non-compliance by operators

103

(4)

Actions to improve compliance

107

(2)

Alienation

109

(1)

Postscript

110

(2)

Accidents that could by prevented by better management

112

(17)

An accident caused by insularity

114

(1)

An accident due to amateurism

115

(1)

The fire at King's Cross railway station

116

(1)

The Herald of Free Enterprise

117

(1)

The Clapham Junction railway accident

118

(2)

Piper Alpha

120

(1)

What more can senior managers do?

120

(5)

The measurement of safety

125

(2)

Conclusions

127

(2)

The probability of human error

129

(25)

Why do we need to know human error rates?

130

(2)

Human error rates - a simple example

132

(1)

A more complex example

132

(4)

Other estimates of human error rates

136

(5)

Two more simple examples

141

(3)

Button pressing

144

(2)

Non-process operations

146

(1)

Train driver errors

147

(1)

Some pitfalls in using data on human reliability

147

(2)

Data on equipment may be data on people

149

(2)

Who makes the errors?

151

(1)

Conclusions

151

(3)

Some accidents that could be prevented by better design

154

(14)

Isolation of protective equipment

155

(1)

Better information display

156

(1)

Pipe failures

156

(3)

Vessel failures

159

(1)

The Sellafield leak

159

(2)

Other design errors

161

(1)

Conceptual shortcomings

162

(3)

Problems of design contractors

165

(1)

Domestic accidents

166

(2)

Some accidents that could be prevented by better construction

168

(7)

Pipe failures

168

(2)

Miscellaneous incidents

170

(3)

Prevention of construction errors

173

(2)

Some accidents that could be prevented by better maintenance

175

(12)

Incidents which occurred because people did not understand how equipment worked

175

(3)

Incidents which occurred because of poor maintenance practice

178

(2)

Incidents due to gross ignorance or incompetence

180

(1)

Incidents which occurred because people took short cuts

181

(2)

Incidents which could be prevented by more frequent of better maintenance

183

(2)

Can we avoid the need for so much maintenance?

185

(2)

Some accidents that could be prevented by better methods of operation

187

(16)

Permits-to-work

187

(2)

Tanker incidents

189

(3)

Some incidents that could be prevented by better instructions

192

(1)

Some incidents involving hoses

193

(1)

Communication failures

194

(5)

Examples from the railways

199

(2)

Simple causes in high tech industries

201

(2)

Errors in computer-controlled plants

203

(18)

Hardware failures

204

(1)

Software errors

205

(2)

Specification errors

207

(3)

Misjudging responses to a computer

210

(3)

Entering the wrong data

213

(1)

Failures to tell operators of changes in data or programs

214

(1)

Unauthorized interference with hardware of software

214

(3)

The hazards of old software

217

(1)

Other applications of computers

217

(1)

Conclusions

218

(3)

Personal and managerial responsibility

221

(13)

Personal responsibility

221

(2)

Legal views

223

(4)

Blame in accident investigations

227

(1)

Managerial wickedness

228

(1)

Managerial competence

229

(2)

Possible and necessary

231

(3)

The adventures of Joe Soap and John Doe

234

(20)

Some final thoughts

254

(3)

Postscript

257

(1)

Appendix 1 - Influences on morale

258

(3)

Appendix 2 - Some myths of human error

261

(8)

Appendix 3 - Some thoughts on sonata form

269

(2)

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An Engineer's View of Human Error, Third Edition

Summary

Table of Contents

Supplemental Materials