An Engineer's View of Human Error, Third Edition

Cover -- Half Title -- Title Page -- Copyright Page -- Foreword to the third edition -- Table of Contents -- 1: Introduction -- 1.1 Accept men as we find them -- 1.2 Meccano or dolls? -- 1.3 Types of human error -- 1.4 Two simple examples -- 1.5 Accident investigation -- 1.6 A story -- 1.7 Research on human error -- 2: Accidents caused by simple slips -- 2.1 Introduction -- 2.2 Forgetting to open or close a valve -- 2.3 Operating the wrong valve -- 2.4 Pressing the wrong button -- 2.5 Failures to notice -- 2.6 Wrong connections -- 2.7 Errors in calculations -- 2.8 Other medical errors -- 2.9 Railways -- 2.10 Other industries -- 2.11 Everyday life (and typing) -- 2.12 Fatigue -- 3: Accidents that could be prevented by better training or instructions -- 3.1 Introduction -- 3.2 Three Mile Island -- 3.3 Other accidents that could be prevented by relatively sophisticated training -- 3.4 Accidents that could be prevented by elementary training -- 3.5 Contradictory instructions -- 3.6 Knowledge of what we don't know -- 3.7 Some simple ways of improving instructions -- 3.8 Training or instructions? -- 3.9 Cases when training is not the best answer -- 4: Accidents due to a lack of physical or mental ability -- 4.1 People asked to do the physically difficult or impossible -- 4.2 People asked to do the mentally difficult or impossible -- 4.3 Individual traits and accident proneness -- 4.4 Mind-sets -- 5: Accidents due to failures to follow instructions -- 5.1 Accidents due to non-compliance by managers -- 5.2 Accidents due to non-compliance by operators -- 5.3 Actions to improve compliance -- 5.4 Alienation -- 5.5 Postscript -- 6: Accidents that could by prevented by better management -- 6.1 An accident caused by insularity -- 6.2 An accident due to amateurism -- 6.3 The fire at King's Cross railway station -- 6.4 The Herald of Free Enterprise

6.5 The Clapham Junction railway accident -- 6.6 Piper Alpha -- 6.7 What more can senior managers do? -- 6.8 The measurement of safety -- 6.9 Conclusions -- 7: The probability of human error -- 7.1 Why do we need to know human error rates? -- 7.3 A more complex example -- 7.2 Human error rates - a simple example -- 7.4 Other estimates of human error rates -- 7.5 Two more simple examples -- 7.6 Button pressing -- 7.7 Non-process operations -- 7.8 Train driver errors -- 7.9 Some pitfalls in using data on human reliability -- 7.10 Data on equipment may be data on people -- 7.11 Who makes the errors? -- 7.12 Conclusions -- 8: Some accidents that could be prevented by better design -- 8.1 Isolation of protective equipment -- 8.2 Better information display -- 8.3 Pipe failures -- 8.4 Vessel failures -- 8.5 The Sellafield leak -- 8.6 Other design errors -- 8.7 Conceptual shortcomings -- 8.8 Problems of design contractors -- 8.9 Domestic accidents -- 9: Some accidents that could be prevented by better construction -- 9.1 Pipe failures -- 9.2 Miscellaneous incidents -- 9.3 Prevention of construction errors -- 10: Some accidents that could be prevented by better maintenance -- 10.1 Incidents which occurred because people did not understand how equipment worked -- 10.2 Incidents which occurred because of poor maintenance practice -- 10.3 Incidents due to gross ignorance or incompetence -- 10.4 Incidents which occurred because people took short cuts -- 10.5 Incidents which could be prevented by more frequent or better maintenance -- 10.6 Can we avoid the need for so much maintenance? -- 11: Some accidents that could be prevented by better methods of operation -- 11.1 Permits-to-work -- 11.2 Tanker incidents -- 11.3 Some incidents that could be prevented by better instructions -- 11.4 Some incidents involving hoses -- 11.5 Communication failures

11.6 Examples from the railways -- 11.7 Simple causes in high tech industries -- 12: Errors in computer-controlled plants -- 12.1 Hardware failures -- 12.2 Software errors -- 12.3 Specification errors -- 12.4 Misjudging responses to a computer -- 12.5 Entering the wrong data -- 12.6 Failures to tell operators of changes in data or progranns -- 12.7 Unauthorized interference with hardware or software -- 12.8 The hazards of old software -- 12.9 Other applications of computers -- 12.10 Conclusions -- 13: Personal and managerial responsibility -- 13.1 Personal responsibility -- 13.2 Legal views -- 13.3 Blame in accident investigations -- 13.4 Managerial wickedness -- 13.5 Managerial competence -- 13.6 Possible and necessary -- 14: The adventures of Joe Soap and John Doe -- 15: Some final thoughts -- Postscript -- Appendix 1 - Influences on morale -- Appendix 2 - Some myths of human error -- Appendix 3 - Some thoughts on sonata form -- Further reading -- Index