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The Resource The Blame Machine : Why Human Error Causes Accidents

The Blame Machine : Why Human Error Causes Accidents

Label
The Blame Machine : Why Human Error Causes Accidents
Title
The Blame Machine
Title remainder
Why Human Error Causes Accidents
Creator
Contributor
Subject
Genre
Language
eng
Summary
The Blame Machine describes how disasters and serious accidents result from recurring, but potentially avoidable, human errors. It shows how such errors are preventable because they result from defective systems within a company. From real incidents, you will be able to identify common causes of human error and typical system deficiencies that have led to these errors. On a larger scale, you will be able to see where, in the organisational or management systems, failure occurred so that you can avoid them. The book also describes the existence of a 'blame culture' in many organisations, which focuses on individual human error whilst ignoring the system failures that caused it. The book shows how this 'blame culture' has, in the case of a number of past accidents, dominated the accident enquiry process hampering a proper investigation of the underlying causes. Suggestions are made about how progress can be made to develop a more open culture in organisations, both through better understanding of human error by managers and through increased public awareness of the issues. The book brings together documentary evidence from recent major incidents from all around the world and within the Rail, Water, Aviation, Shipping, Chemical and Nuclear industries. Barry Whittingham has worked as a senior manager, design engineer and consultant for the chemical, nuclear, offshore oil and gas, railway and aviation sectors. He developed a career as a safety consultant specializing in the human factors aspects of accident causation. He is a member of the Human Factors in Reliability Group, and a Fellow of the Safety and Reliability Society
Cataloging source
MiAaPQ
LC call number
HV675 -- .W48 2004eb
Literary form
non fiction
Nature of contents
dictionaries
Label
The Blame Machine : Why Human Error Causes Accidents
Link
http://ebookcentral.proquest.com/lib/multco/detail.action?docID=288851
Instantiates
Publication
Copyright
Carrier category
online resource
Carrier category code
cr
Carrier MARC source
rdacarrier
Color
multicolored
Content category
text
Content type code
txt
Content type MARC source
rdacontent
Contents
  • Front Cover -- The Blame Machine: Why Human Error Causes Accidents -- Copyright Page -- Contents -- Preface -- Acknowledgements -- Part I: Understanding human error -- 1. To err is human -- 1.1 Defining human error -- 1.1.1 Introduction -- 1.1.2 Swain and Guttman 1983 -- 1.1.3 Reason 1990 -- 1.1.4 Hollnagel 1993 -- 1.1.5 Meister 1966 -- 1.1.6 Characterizing an error -- 1.2 Random and systemic errors -- 1.2.1 Introduction -- 1.2.2 Error causation -- 1.2.3 Human performance -- 1.2.4 Estimating human error probability -- 1.2.5 The balance between random and systemic errors -- 1.2.6 Human error and risk -- References -- 2. Errors in practice -- 2.1 Introduction -- 2.2 Genotypes and phenotypes -- 2.2.1 Definition -- 2.2.2 Example of phenotype/genotype taxonomy -- 2.3 The skill, rule and knowledge taxonomy -- 2.3.1 Definitions -- 2.3.2 Selection of appropriate behaviour type -- 2.3.3 Determination of behaviour type -- 2.4 The generic error modelling system taxonomy -- 2.4.1 Overview -- 2.4.2 Slips and lapses -- 2.4.3 Mistakes -- 2.4.4 Summary -- References -- 3. Latent errors and violations -- 3.1 Introduction -- 3.2 Latent and active errors -- 3.2.1 Introduction -- 3.2.2 Active errors -- 3.2.3 Latent errors -- 3.2.4 Latent errors in maintenance -- 3.2.5 Latent errors in management -- 3.3 Violations -- 3.3.1 Introduction -- 3.3.2 Definition of a violation -- 3.3.3 Distinction between errors and violations -- 3.3.4 Classification of violations -- 3.3.5 The causes and control of violations -- References -- 4. Human reliability analysis -- 4.1 Introduction -- 4.2 Measuring human reliability -- 4.2.1 Introduction -- 4.2.2 Definitions -- 4.2.3 Expressing probability values -- 4.2.4 Performance shaping factors -- 4.2.5 Task complexity -- 4.3 Human reliability methods -- 4.3.1 Database methods -- 4.3.2 Expert judgement methods -- 4.3.3 Conclusion
  • 4.4 Task decomposition -- 4.4.1 Introduction -- 4.4.2 Task analysis -- 4.5 Error identification -- 4.5.1 Introduction -- 4.5.2 Taxonomy based methods -- 4.5.3 Knowledge based methods -- References -- 5. Human error modelling -- 5.1 Introduction -- 5.2 Basic probability theory -- 5.2.1 Introduction -- 5.2.2 Failure and success probability -- 5.2.3 Probability of two or more independent events -- 5.2.4 Combining human error probabilities using logic gates -- 5.2.5 Fault trees -- 5.2.6 Event trees -- 5.3 Error recovery -- 5.3.1 Introduction -- 5.3.2 Error recovery mechanisms -- 5.3.3 Effect of error recovery on error probability -- 5.4 Error dependency -- 5.4.1 Introduction -- 5.4.2 Root causes -- 5.4.3 Coupling between errors -- 5.4.4 The importance of error dependency -- 5.4.5 Dependency modelling -- References -- 6. Human error in event sequences -- 6.1 Introduction -- 6.2 Human reliability event trees -- 6.2.1 Introduction -- 6.2.2 Example human reliability analysis event tree -- 6.2.3 Quantification of error probabilities -- 6.2.4 Event tree logic -- 6.3 Scenario analysis -- 6.3.1 Introduction -- 6.3.2 Scenario 1: Influence of dependency on outcome F3 -- 6.3.3 Scenario 2: Influence of recovery factor in scenario F5 -- 6.4 Overview of human error modelling -- 6.4.1 Introduction -- 6.4.2 Task analysis -- 6.4.3 Error identification -- 6.4.4 Error quantification -- 6.4.5 Human reliability event trees -- Part II: Accident case studies -- 7. Organizational and management errors -- 7.1 Introduction -- 7.2 The Flixborough chemical plant disaster -- 7.2.1 Introduction -- 7.2.2 Description of the cyclohexane process -- 7.2.3 Events leading to the accident -- 7.2.4 The accident -- 7.2.5 The public inquiry -- 7.2.6 Alternative event sequence -- 7.2.7 Epilogue -- 7.2.8 Conclusions -- 7.3 The capsize of the Herald of Free Enterprise -- 7.3.1 The accident
  • 7.3.2 The inquiry -- 7.3.3 Conclusions -- 7.4 Privatization of the railways -- 7.4.1 Introduction -- 7.4.2 Rail safety statistics before and after privatization -- 7.4.3 A brief history of railway safety management -- 7.4.4 The impact of privatization upon safety -- 7.4.5 Conclusion -- References -- 8. Design errors -- 8.1 Introduction -- 8.2 The fire and explosion at BP Grangemouth -- 8.2.1 Introduction -- 8.2.2 Description of the process -- 8.2.3 The accident -- 8.2.4 The investigation -- 8.2.5 Report of the inquiry -- 8.2.6 The design error -- 8.2.7 Conclusion -- 8.3 The sinking of the ferry 'Estonia' -- 8.3.1 Introduction -- 8.3.2 The accident -- 8.3.3 The investigation -- 8.3.4 The causes -- 8.3.5 The aftermath -- 8.3.6 Conclusions -- 8.4 The Abbeystead explosion -- 8.4.1 Introduction -- 8.4.2 The accident -- 8.4.3 The investigation -- 8.4.4 The aftermath -- 8.4.5 Conclusion -- References -- 9. Maintenance errors -- 9.1 Introduction -- 9.2 Engine failure on the Royal Flight -- 9.2.1 Introduction -- 9.2.2 The accident -- 9.2.3 Cause of the accident -- 9.2.4 Conclusion -- 9.3 The railway accident at Hatfield -- 9.3.1 Introduction -- 9.3.2 The accident -- 9.3.3 The causes -- 9.3.4 Investigations -- 9.3.5 Conclusions -- 9.4 The railway accident at Potters Bar -- 9.4.1 Introduction -- 9.4.2 Initial investigation - direct causes -- 9.4.3 Later findings - root causes -- 9.4.4 Postscript - the future of rail maintenance? -- References -- 10. Active errors in railway operations -- 10.1 Introduction -- 10.2 Signals passed at danger -- 10.2.1 Introduction -- 10.2.2 The accident at Clapham Junction -- 10.3 The train accident at Purley -- 10.3.1 Introduction -- 10.3.2 The accident -- 10.3.3 The inquiry -- 10.3.4 Conclusion -- 10.4 The driver's automatic warning system -- 10.4.1 System operation -- 10.4.2 A conditioned response
  • 10.4.3 The effect of dependency -- 10.5 The Southall and Ladbroke Grove rail accidents -- 10.5.1 Introduction -- 10.5.2 The Southall rail accident 1997 -- 10.5.3 The Ladbroke Grove accident 1999 -- 10.6 Human error analysis of signals passed at danger -- 10.6.1 Introduction -- 10.6.2 Causes of SPADs -- 10.6.3 Probability of SPADs -- 10.6.4 Human reliability event tree for SPADs -- 10.6.5 Conclusion -- 10.7 Driver protection against SPADs -- 10.7.1 Introduction -- 10.7.2 Train protection and warning system -- 10.7.3 Automatic train protection -- 10.7.4 Conclusion -- References -- 11. Active errors in aviation -- 11.1 Introduction -- 11.2 The loss of flight KAL007 -- 11.2.1 Introduction -- 11.2.2 The accident -- 11.2.3 The causes -- 11.2.4 Conclusions -- 11.3 The Kegworth accident -- 11.3.1 Introduction -- 11.3.2 The accident -- 11.3.3 The causes -- 11.3.4 Conclusion -- References -- 12. Violations -- 12.1 Introduction -- 12.2 The Chernobyl accident -- 12.2.1 Introduction -- 12.2.2 The Chernobyl reactor -- 12.2.3 Problems with the design -- 12.2.4 The accident -- 12.2.5 The causes -- 12.2.6 Conclusions -- 12.3 The Airbus A320 crash at Mulhouse -- 12.3.1 Introduction -- 12.3.2 The A320 Airbus -- 12.3.3 The accident at Mulhouse -- 12.3.4 Conclusions -- References -- 13. Incident response errors -- 13.1 Introduction -- 13.2 Fire on Swissair flight SR111 -- 13.2.1 Introduction -- 13.2.2 The accident -- 13.2.3 The causes -- 13.2.4 Conclusion -- 13.3 The Channel Tunnel fire -- 13.3.1 Introduction -- 13.3.2 Channel Tunnel description -- 13.3.3 The accident -- 13.3.4 The causes and development of the fire -- 13.3.5 The emergency response -- 13.3.6 Conclusions -- References -- 14. Conclusions -- 14.1 Human error and blame -- 14.2 Understanding human error -- 14.3 Human error in industry -- References -- Appendix: Train protection systems -- Index
Control code
EBC288851
Dimensions
unknown
Edition
1st ed.
Extent
1 online resource (284 pages)
Form of item
online
Isbn
9780080472126
Media category
computer
Media MARC source
rdamedia
Media type code
c
Note
Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, 2017. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries.
Sound
unknown sound
Specific material designation
remote
System control number
  • (MiAaPQ)EBC288851
  • (Au-PeEL)EBL288851
  • (CaPaEBR)ebr10169781
  • (CaONFJC)MIL96637
  • (OCoLC)469402228
Label
The Blame Machine : Why Human Error Causes Accidents
Link
http://ebookcentral.proquest.com/lib/multco/detail.action?docID=288851
Publication
Copyright
Carrier category
online resource
Carrier category code
cr
Carrier MARC source
rdacarrier
Color
multicolored
Content category
text
Content type code
txt
Content type MARC source
rdacontent
Contents
  • Front Cover -- The Blame Machine: Why Human Error Causes Accidents -- Copyright Page -- Contents -- Preface -- Acknowledgements -- Part I: Understanding human error -- 1. To err is human -- 1.1 Defining human error -- 1.1.1 Introduction -- 1.1.2 Swain and Guttman 1983 -- 1.1.3 Reason 1990 -- 1.1.4 Hollnagel 1993 -- 1.1.5 Meister 1966 -- 1.1.6 Characterizing an error -- 1.2 Random and systemic errors -- 1.2.1 Introduction -- 1.2.2 Error causation -- 1.2.3 Human performance -- 1.2.4 Estimating human error probability -- 1.2.5 The balance between random and systemic errors -- 1.2.6 Human error and risk -- References -- 2. Errors in practice -- 2.1 Introduction -- 2.2 Genotypes and phenotypes -- 2.2.1 Definition -- 2.2.2 Example of phenotype/genotype taxonomy -- 2.3 The skill, rule and knowledge taxonomy -- 2.3.1 Definitions -- 2.3.2 Selection of appropriate behaviour type -- 2.3.3 Determination of behaviour type -- 2.4 The generic error modelling system taxonomy -- 2.4.1 Overview -- 2.4.2 Slips and lapses -- 2.4.3 Mistakes -- 2.4.4 Summary -- References -- 3. Latent errors and violations -- 3.1 Introduction -- 3.2 Latent and active errors -- 3.2.1 Introduction -- 3.2.2 Active errors -- 3.2.3 Latent errors -- 3.2.4 Latent errors in maintenance -- 3.2.5 Latent errors in management -- 3.3 Violations -- 3.3.1 Introduction -- 3.3.2 Definition of a violation -- 3.3.3 Distinction between errors and violations -- 3.3.4 Classification of violations -- 3.3.5 The causes and control of violations -- References -- 4. Human reliability analysis -- 4.1 Introduction -- 4.2 Measuring human reliability -- 4.2.1 Introduction -- 4.2.2 Definitions -- 4.2.3 Expressing probability values -- 4.2.4 Performance shaping factors -- 4.2.5 Task complexity -- 4.3 Human reliability methods -- 4.3.1 Database methods -- 4.3.2 Expert judgement methods -- 4.3.3 Conclusion
  • 4.4 Task decomposition -- 4.4.1 Introduction -- 4.4.2 Task analysis -- 4.5 Error identification -- 4.5.1 Introduction -- 4.5.2 Taxonomy based methods -- 4.5.3 Knowledge based methods -- References -- 5. Human error modelling -- 5.1 Introduction -- 5.2 Basic probability theory -- 5.2.1 Introduction -- 5.2.2 Failure and success probability -- 5.2.3 Probability of two or more independent events -- 5.2.4 Combining human error probabilities using logic gates -- 5.2.5 Fault trees -- 5.2.6 Event trees -- 5.3 Error recovery -- 5.3.1 Introduction -- 5.3.2 Error recovery mechanisms -- 5.3.3 Effect of error recovery on error probability -- 5.4 Error dependency -- 5.4.1 Introduction -- 5.4.2 Root causes -- 5.4.3 Coupling between errors -- 5.4.4 The importance of error dependency -- 5.4.5 Dependency modelling -- References -- 6. Human error in event sequences -- 6.1 Introduction -- 6.2 Human reliability event trees -- 6.2.1 Introduction -- 6.2.2 Example human reliability analysis event tree -- 6.2.3 Quantification of error probabilities -- 6.2.4 Event tree logic -- 6.3 Scenario analysis -- 6.3.1 Introduction -- 6.3.2 Scenario 1: Influence of dependency on outcome F3 -- 6.3.3 Scenario 2: Influence of recovery factor in scenario F5 -- 6.4 Overview of human error modelling -- 6.4.1 Introduction -- 6.4.2 Task analysis -- 6.4.3 Error identification -- 6.4.4 Error quantification -- 6.4.5 Human reliability event trees -- Part II: Accident case studies -- 7. Organizational and management errors -- 7.1 Introduction -- 7.2 The Flixborough chemical plant disaster -- 7.2.1 Introduction -- 7.2.2 Description of the cyclohexane process -- 7.2.3 Events leading to the accident -- 7.2.4 The accident -- 7.2.5 The public inquiry -- 7.2.6 Alternative event sequence -- 7.2.7 Epilogue -- 7.2.8 Conclusions -- 7.3 The capsize of the Herald of Free Enterprise -- 7.3.1 The accident
  • 7.3.2 The inquiry -- 7.3.3 Conclusions -- 7.4 Privatization of the railways -- 7.4.1 Introduction -- 7.4.2 Rail safety statistics before and after privatization -- 7.4.3 A brief history of railway safety management -- 7.4.4 The impact of privatization upon safety -- 7.4.5 Conclusion -- References -- 8. Design errors -- 8.1 Introduction -- 8.2 The fire and explosion at BP Grangemouth -- 8.2.1 Introduction -- 8.2.2 Description of the process -- 8.2.3 The accident -- 8.2.4 The investigation -- 8.2.5 Report of the inquiry -- 8.2.6 The design error -- 8.2.7 Conclusion -- 8.3 The sinking of the ferry 'Estonia' -- 8.3.1 Introduction -- 8.3.2 The accident -- 8.3.3 The investigation -- 8.3.4 The causes -- 8.3.5 The aftermath -- 8.3.6 Conclusions -- 8.4 The Abbeystead explosion -- 8.4.1 Introduction -- 8.4.2 The accident -- 8.4.3 The investigation -- 8.4.4 The aftermath -- 8.4.5 Conclusion -- References -- 9. Maintenance errors -- 9.1 Introduction -- 9.2 Engine failure on the Royal Flight -- 9.2.1 Introduction -- 9.2.2 The accident -- 9.2.3 Cause of the accident -- 9.2.4 Conclusion -- 9.3 The railway accident at Hatfield -- 9.3.1 Introduction -- 9.3.2 The accident -- 9.3.3 The causes -- 9.3.4 Investigations -- 9.3.5 Conclusions -- 9.4 The railway accident at Potters Bar -- 9.4.1 Introduction -- 9.4.2 Initial investigation - direct causes -- 9.4.3 Later findings - root causes -- 9.4.4 Postscript - the future of rail maintenance? -- References -- 10. Active errors in railway operations -- 10.1 Introduction -- 10.2 Signals passed at danger -- 10.2.1 Introduction -- 10.2.2 The accident at Clapham Junction -- 10.3 The train accident at Purley -- 10.3.1 Introduction -- 10.3.2 The accident -- 10.3.3 The inquiry -- 10.3.4 Conclusion -- 10.4 The driver's automatic warning system -- 10.4.1 System operation -- 10.4.2 A conditioned response
  • 10.4.3 The effect of dependency -- 10.5 The Southall and Ladbroke Grove rail accidents -- 10.5.1 Introduction -- 10.5.2 The Southall rail accident 1997 -- 10.5.3 The Ladbroke Grove accident 1999 -- 10.6 Human error analysis of signals passed at danger -- 10.6.1 Introduction -- 10.6.2 Causes of SPADs -- 10.6.3 Probability of SPADs -- 10.6.4 Human reliability event tree for SPADs -- 10.6.5 Conclusion -- 10.7 Driver protection against SPADs -- 10.7.1 Introduction -- 10.7.2 Train protection and warning system -- 10.7.3 Automatic train protection -- 10.7.4 Conclusion -- References -- 11. Active errors in aviation -- 11.1 Introduction -- 11.2 The loss of flight KAL007 -- 11.2.1 Introduction -- 11.2.2 The accident -- 11.2.3 The causes -- 11.2.4 Conclusions -- 11.3 The Kegworth accident -- 11.3.1 Introduction -- 11.3.2 The accident -- 11.3.3 The causes -- 11.3.4 Conclusion -- References -- 12. Violations -- 12.1 Introduction -- 12.2 The Chernobyl accident -- 12.2.1 Introduction -- 12.2.2 The Chernobyl reactor -- 12.2.3 Problems with the design -- 12.2.4 The accident -- 12.2.5 The causes -- 12.2.6 Conclusions -- 12.3 The Airbus A320 crash at Mulhouse -- 12.3.1 Introduction -- 12.3.2 The A320 Airbus -- 12.3.3 The accident at Mulhouse -- 12.3.4 Conclusions -- References -- 13. Incident response errors -- 13.1 Introduction -- 13.2 Fire on Swissair flight SR111 -- 13.2.1 Introduction -- 13.2.2 The accident -- 13.2.3 The causes -- 13.2.4 Conclusion -- 13.3 The Channel Tunnel fire -- 13.3.1 Introduction -- 13.3.2 Channel Tunnel description -- 13.3.3 The accident -- 13.3.4 The causes and development of the fire -- 13.3.5 The emergency response -- 13.3.6 Conclusions -- References -- 14. Conclusions -- 14.1 Human error and blame -- 14.2 Understanding human error -- 14.3 Human error in industry -- References -- Appendix: Train protection systems -- Index
Control code
EBC288851
Dimensions
unknown
Edition
1st ed.
Extent
1 online resource (284 pages)
Form of item
online
Isbn
9780080472126
Media category
computer
Media MARC source
rdamedia
Media type code
c
Note
Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, 2017. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries.
Sound
unknown sound
Specific material designation
remote
System control number
  • (MiAaPQ)EBC288851
  • (Au-PeEL)EBL288851
  • (CaPaEBR)ebr10169781
  • (CaONFJC)MIL96637
  • (OCoLC)469402228

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